Provider News New YorkApril 2021 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Did you know your Availity administrator for your organization is the key to opening doors to self-service transaction roles such as EDI? A role is a group of job functions, also known as permissions. Each role consists of one or more permissions. Assigning roles is part of the process when you add a new Availity user with the Add User feature.
What EDI roles do I need?
EDI Management - This role consists of the following permissions available under EDI File Management in the Availity menu:
- EDI reporting preferences– Specify the EDI batch report files you want users at your organization to receive, along with file formats and other reporting preferences.
- EDI send and receive files– Review EDI batch report files for batch files submitted using Availity's EDI File Management feature. In addition, review payer responses to Availity Web-based claim forms submitted to payers that process claims in batches.
- File restore– Restore archived EDI files to your Receive Files
Set up EDI reporting preferences
Availity's batch EDI processing generates response files for each batch file that you submit. The administrator for an organization can set reporting preferences that specify which response files are generated. In the Availity Portal menu, click Claims & Payments > EDI reporting preferences.
Enroll for the Direct Data Entry Transaction
You must be assigned the Claims role to submit professional claims or encounters. If you cannot access the claim form, contact your administrator to assign the Claims role to you. Submit transactions through manual data entry in Availity Portal. In the Availity Portal menu, click Claims & Payments > Professional Claim/Facility Claim/Dental Claim < Confirm which organization and payer you would like to submit claims for and continue to complete the fields to be directed to the simple and time saving claim form to enter claim information.
Need More Help?
The EDI Connection Services Startup Guide is a helpful resource to help you get started, set up your EDI reporting preferences and submit transactions through manual data entry in Availity Portal.
Contact Availity
- Select Help & Training > Get Trained to display the Availity Learning Center (ALC) in a new browser tab. Search the catalog to locate and enroll in courses. Based on your needs.
- Select Help & Training > Find Help to display Availity Help in a new browser window. Use Contents to display topics. Depending on your needs, consider exploring these topics:
- Administrator
- Claim Submission
- Electronic Data Interchange (EDI)
- Glossary
- Select Help & Training > Availity Support to:
- Open a ticket to request support
- Get support via Chat
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The fast, easy way to have your questions answered
If you have questions about prior authorizations (PA), you now have a new option to have them answered quickly and easily. With EmpireChat, providers can have a real-time, online discussion with a PA specialist.
- Faster access to PA provider services experts
- Real-time answers to your questions about PA and live help for submissions, like the call experience
- Access to denial information and clinical team for resolution
- The same high level of safety and security you have come to expect with Empire
Chat is one example of how Empire is using digital technology to improve the healthcare experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.
To access chat: log on to Availity at www.Availity.com. Select Payer Spaces then select the health plan. Once in Payer Spaces, select the Chat with Payer box from Applications.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Centers for Medicare & Medicaid Services (CMS) has issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement Application Programming Interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates, that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS has identified Health Level 7 ® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.
Empire BlueCross BlueShield’s (“Empire”) Clinical Data Acquisition Group has integrated Admission, Discharge and Transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange can help Empire:
- Better support members with care coordination and discharge planning – leading to healthier outcomes for our members – your patients.
- Proactively manage care transitions to avoid waste.
- Close care gaps and educate members about appropriate care settings to better manage out-of-pocket expenses.
Empire would like to digitally exchange HLT ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Empire through these channels as well. Near real time HL7 ADT messaging data, or at least within 24-hours of admission, discharge or transfer, enables Empire to most effectively manage care transitions.
Contact the Clinical Data and Analytics team to get started today. Email: ADT_Intake@Anthem.com
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) is committed to reducing cost while improving health outcomes. To that end, effective April 1, 2021 Empire will be changing how you submit Appeals for all clinically denied appeals related to commercial business.
Submission through Interactive Care Reviewer (ICR) allows you to 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. It’s as easy as 1,2,3!
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
- 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.
You can still initiate an appeal by calling or writing to the Empire Medical Management Appeals:
Call 1- 800-634-5605, 8:30 a.m. to 5:00 p.m. EST, Monday – Friday,
Or
Writing to:
Grievance and Appeals Department
PO Box 5063
Middletown, New York 10940
Or
Retro-Service Appeal Fax # (877) 278-2163
Pre-Service Appeal Fax # (888) 694-1545
For all fax and mail in appeal requests, the Provider Clinical Appeal Request cover sheet must be filled out and sent in the with the appeal.
Providers submitting Appeals on behalf of a patient must have a Designation of Representation (DOR) form signed by the patient and submitted with this request if not already submitted.
Definition
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Expedited Appeal:
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An Appeal of a review of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, mental health and/or substance use disorder services that may be subject to a court order, or any other urgent matter.
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· If your request does not meet the definition of an expedited appeal, it will follow the standard appeal timeframes.
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For your claim payment grievance to be processed, the following information should be included:
- A description of why you believe the claim was not processed correctly (e.g., underpayment; incorrect payment)
- Member Name
- Member ID Number with Prefix
- Date of Service
- Provider Name, NPI and Tax ID Number
- Any other relevant info (EOB, etc.)
Upon receipt of a claim payment grievance and supporting documentation, we will make reasonable efforts to issue a decision within 30 days.
If you submit your request for a claim payment grievance after the 180-day timeframe has expired, you will have waived your right to file a claim payment grievance with Empire. Empire will not accept any grievance requests after 180 days nor make any claim payment adjustments if a grievance is not submitted timely.
Please note: The above relates to the provider’s ability to dispute the payment of a claim that does not involve medical necessity. There is a separate process for member grievances and/or appeals as outlined under their benefit plan and further clarified in this manual.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) and Availity are excited to announce the Prior Authorization/Referrals 278 and Inpatient Admission and Discharge Notification 278N 5010 transactions functionality.
Authorization and Referral Request (278)
Use this transaction to electronically submit authorization and referral requests. You have the option to transmit this transaction in real-time or batch mode, and you will receive confirmation numbers to validate receipt of request.
- An authorization is a review and approval of specific services
- A referral is used to refer a patient to a specialty provider
Hospital admission notification (278N)
Use this transaction to electronically submit hospital admission notifications between your facility and health plan. The EDI 278N is the easiest, most efficient way to communicate facility admissions. Just like the 278, you can also transmit in either batch or real-time format which includes the ability to update a previously submitted date.
What are your benefits for using these transactions?
- Streamline administrative tasks and increase productivity
- Reduce administrative costs through automation
- Increase data accuracy by reducing manual errors
- Confirm a notification of admission is on file in the form of a service reference number that is generated upon registration
- Submit notification of discharge
- Accomplish more with less ‒ fewer phone calls, faxes or keying
Getting started
- If you use a clearinghouse or vendor work with them to ensure they have the capability to exchange these transactions.
- If you use practice management software have your Availity administrator use the following path to enroll:
- My Providers > Enrollment Center > Transaction Enrollment
Useful documents
If you need assistance, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 8 p.m. Eastern Time.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Information Center is replacing the Education and Reference Center application in Payer Spaces on the Availity Portal. There you’ll find important policies, forms and helpful resources.
If you’re looking for specific education materials, we invite you to visit the Custom Learning Center in Availity, which was designed to offer education/training content and to be a learning environment. Content previously posted in the Communication & Education tab have now migrated there. Find the Custom Learning Center tool in Payer Spaces > Applications > Access the Custom Learning Center.
Locate the Information Center in Payer Spaces. Depending on your market, the Information Center contains several sections:
- Administrative Support
- Behavioral Health
- Clinical Resources
- Medicaid
- Medicare
- Federal Employee Program (FEP)
To view content in both valuable tools, visit Payer Spaces today.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In March we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if outpatient services require prior authorization for members enrolled in Empire BlueCross BlueShield’s (“Empire”) commercial plans.
In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:
- Medical Policies and Clinical Guidelines
- Third Party Guidelines, if applicable (such as AIM Specialty Health, Inferior)
Steps to access the Authorization Lookup application through Availity Payer Spaces
Access to the tool does not require an Availity role assignment.
- Select Payer Spaces
- Select the Empire BlueCross BlueShield tile from the Payer Spaces menu
- Select the Applications tab
- Select the Authorization Rules Lookup tile
Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:
- Tax ID
- National Provider Identifier (NPI)
- Member ID and birth date
- Member’s Group number or Contract Code (This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)
Give this new tool a try and discover how much this will improve the efficiency of your authorization process.
Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Empire’s online authorization tool which you can also access through the Availity Portal.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) is committed to continuous improvement to meet the ever-changing needs of the health care industry. To move toward standardization of contract language as the result of a recent move to a new contract management system, you may receive an updated Participating Provider Agreement later this month if your individual participation with Empire began prior to January 1, 2016.
What is the impact of this change?
Please note there are no changes to billing procedures, reimbursements, lines of business or networks that you currently participate in as a network provider. In addition, the new Agreement does not alter your original effective date of participation, but it does replace your old participating provider agreement with us.
What do I need to do?
In order for your participation in our network to continue unaffected, please review, sign and return the signature page(s) along with the lobbying and disclosure statements (if applicable) to Empire via email at recontracting@empireblue.com.
If you are unable to return via the preferred method above, please either fax or mail to the addresses below
Fax: 1-855-841-4618
Mail: Empire BlueCross BlueShield
9 Pine Street, 21st Floor
New York, NY 10005
If you have any questions or concerns, please contact us as above within 30 days following receipt of this Agreement.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective October 1, 2020 Anthem became the sole medical carrier for the State of Connecticut Employer Group and the Connecticut Partnership Plan.
Members with the State BlueCare plans listed below have out of area privileges and can be seen by New York Empire BlueCross BlueShield (“Empire”) providers who are participating in the Empire HMO and/or Traditional network. Please see blank suitcase in the sample ID card below which indicates their national out of area privileges. These members should be considered BlueCard eligible members and claims submission should follow those rules. The majority of State and Partnership members have a BlueCare plan.
Members with the State Preferred plan (only) will use the PPO network and submit through BlueCard.
Network Name
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Product Type
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State of Connecticut
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State Partnership
Plan
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State
Preferred
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PPO
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XGS
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State BlueCare
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HMO - Point of Service (PCP referral not required)
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XGR
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SHP
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State BlueCare
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HMO - Point of Enrollment (PCP referral not required)
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XGT
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State BlueCare
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HMO - Point of Enrollment (PCP referral required)
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XGL
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State BlueCare Prime (Narrow Network)
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HMO (PCP referral required)
NOT A TIERED PLAN
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X6G
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Submit a request for review to AIM
As communicated in the October 2020 Newsletter, ordering providers may submit prior authorization requests for the hospital outpatient site of care for applicable procedures for dates of service on or after January 1, 2021 to AIM in one of the following ways:
- Access AIM’s ProviderPortalSM 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 at 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
AIM will offer webinars to provide information on navigating the AIM ProviderPortal. For more information visit: aimproviders.com/surgical procedures
Providers should always use the Empire BlueCross BlueShield (“Empire”) assigned member ID number and continue to verify eligibility and benefits for all members prior to rendering services.
The AIM reviews apply to local fully insured Empire members and any member covered under self-insured (ASO) benefit plans with services medically managed by AIM; to include the City of NY.
They do not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®) or ASO benefit plans where services are not medically managed by AIM. Providers can view specific guidelines and prior authorization requirements for Empire members on the Prior Authorization page of our empireblue.com/provider.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Healthcare and mental healthcare professionals have a vital role in identifying, treating, and addressing racial trauma and injustice, moving our communities towards racial equity, and improving the health and wellbeing of all Americans.
We can impact the injustice of racism together.
Empire BlueCross BlueShield (“Empire”) has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to take on the challenge of facilitating conversations on racial injustice, trauma, and inequality among our providers and associates.
We are hosting Racial Equity forums on a quarterly basis to keep the conversation going. Please register for the next forum, Deconstructing Bias, to learn more about the impact of racism on healthcare and the people we serve, and what we can do about it.
In Pursuit of Racial Equity: Deconstructing Bias
Wednesday, June 9th, 2021 4:00 pm – 5:30 pm Eastern, (1:00 pm – 2:30 pm Pacific)
Register today!
Our racial equity forums focus on:
- Exploring how racism takes shape in healthcare.
- Discussing how to identify racism in your practice and how to be an ally to your patients.
- Understanding the impact of prolonged exposure to racism on people of .
- Providing you with actionable resources to put an end to racism in your practice.
Since October 2020, Empire has sponsored two virtual forums featuring healthcare professionals from Empire and Motivo: Racial Trauma in America and The Road to Allyship: Playing Your Part in Racial Equity.
We know we are on the right track because the racial equity forum participants say so.
- 90% received meaningful information about the influence that racism and white privilege may have on their perspectives and gained an understanding on what actions they can take to make a difference and be an ally.
- 86% obtained useful information and resources that will enhance their ability to serve patients.
- 75% agreed that the forum helped them understand a different perspective.
- 76% had some of their perspectives and beliefs challenged.
Systematic racism is a part of today’s healthcare system.
- US physicians underestimate the pain level of Black patients 47% of the time vs. 33.5% of the time for white patients (PNAS).
- Black women die from pregnancy or childbirth 243% more often than white women (CDC).
The first step to addressing racism is to recognize its existence, subtle or otherwise.
These conversations can be uncomfortable, but this is how you can do something about racial injustice now.
At Empire, we are determined to reduce racism in our communities with your support and participation.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.
We encourage providers to utilize the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.
Visit empireblue.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In May 2020, the Centers for Disease Control (CDC) released a report that showed a drop in routine childhood vaccinations as a result of COVID-19; a result of stay at home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and
the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.
To encourage well-visits and vaccinations, here are some extra steps you can take, if you haven’t already, to make visits as safe as possible for both patients and staff. They include:
- Scheduling sick visits and well-child visits during different times of the day.
- Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms.
- Offering sick visits and well-child visits in different locations.
It’s important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.
Important update from The National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They reemphasized the significance of this delay and suggest that providers administer childhood immunizations as soon as needed through proactively scheduling and preplanning.
Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three Hiba (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
Billing codes:
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
Billing Codes:
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Empire BlueCross BlueShield (“Empire”) contracted laboratories and identify the proper CPT codes to use.
Contact your Empire representative if you need additional information or visit empireblue.com/coronavirus/providers.
COVID-19 testing coding guidelines
- For a new or established patient, CPT code 99211 would be appropriate if patient is being seen for no other services besides a specimen collection.
- For a patient assessment in addition to a specimen collection it is appropriate to bill the applicable E&M service, CPT codes 99202-99215. Specimen collection is a component of the E&M service and not separately reimbursable. Effective 04/01/2021, CPT codes G2023 and G2024 are appropriate when billed by clinical laboratories only and are not appropriate for provider practices.
Refer patients to empireblue.com/coronavirus to find convenient testing locations
If an Empire member requests a COVID-19 test, you may refer them to empireblue.com or the Sydney Health mobile app to find testing locations near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:
- Appointments or walk-ins.
- Drive-through service.
- Rapid test results.
- Antibody testing.
- Testing for children.
Send swab tests to Empire-contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high value health care.
Consider antigen testing when rapid test results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), e.g. PCR. Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
Antigen tests can be used to detect current infection, are relatively easy to use, and most can provide point-of-care testing results. The Centers for Disease Control and Prevention (CDC) notes that proper interpretation of antigen test results (and confirmatory testing with NAAT when indicated) is important for accurate clinical management of patients with suspected COVID-19; more information can be found here.
The CDC notes that when molecular tests are unavailable or rapid turnaround time is needed, antigen tests can generally be used for diagnosis of COVID-19.
Antigen tests are typically less sensitive, and clinicians should interpret negative results carefully. When symptoms are present or a high clinical suspicion exists, negative antigen tests should be confirmed with a molecular test.
When antigen tests are used in symptomatic patients, positive antigen tests can be interpreted as indicative of SARS-CoV-2 infection and do not usually require follow-up testing.
Consider using COVID-19 and flu combination testing when appropriate
According to the CDC, clinicians should consider testing for other causes of respiratory illness, including infections such as influenza, when clinically appropriate.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Blue Cross Blue Shield Association recently published an updated study that showed a downward trend in the physical health of millennials (those born between 1981 and 1996) driven largely by behavioral health conditions. There were notable increases in major depression (12%), alcohol use disorder (7%) and tobacco and substance use disorders (5%).
Millennials with behavioral health conditions were at twice the risk of having a chronic physical condition.
The study included the analysis of millennials’ medical claims over a five year period. Those with ongoing behavioral health conditions were twice as likely to have a chronic physical condition as their peers without a behavioral health diagnosis.
Behavioral health conditions driving adverse health for millennials
It’s important to follow-up with your patients - millennial, Gen X, Gen Z or baby boomer, who are prescribed antidepressant medications or who have been hospitalized for mental illness or substance use disorders. Not only will patients have better behavioral health outcomes, their physical health could be significantly impacted as well. Follow these HEDIS® measures for additional guidance in closing the gaps in behavioral health conditions for all ages.
A note about telehealth
NCQA now accepts telehealth codes for behavioral health and some physical health measures. The modifiers 95 and GT are defined as telehealth services rendered via interactive audio and video telecommunications system. CPT Codes 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 98960-98962, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99409 and 99495-99496 may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95.
AMM - Antidepressant Medication Management (AMM): The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported:
- Effective acute phase treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
- Effective continuation phase treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).
AIM Billing Codes:
- BH Outpatient CPT: 99078, 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99510 HCPCS: G0155, G0176-G0177, G0409, G0463, H0002, H0004, H0031, H0034-H0037, H0039-H0040, H2000, H2001, H2010-H2011, M0064, T1015
- Emergency Department CPT: 99281-99285 UB Rev: 0450-0452, 0456, 0459, 0981
- Major Depression ICD-10 CM: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9
- Telephone Visits CPT: 98966-98968, 99441-99443
- Telephone Modifier Value Set: 95 GT POS: 02
- Telehealth: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
- Telehealth modifier: 95 or GT
- Telehealth POS: 02
FUH - Follow-up after hospitalization for mental illness (FUH) - The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported:
- The percentage of discharges for which the member received follow-up within 30 days after discharge.
- The percentage of discharges for which the member received follow-up within 7 days after discharge.
The follow-up visits, within 7 days and 30 days after hospitalization can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUH billing codes:
- Follow-up visits CPT: 90791-2, 90832-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510 HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
- Mental illness diagnosis codes ICD-10: F03.9x, F20-F25.xx, F28-F34.xx, F39-F45.xx, F48.xx, F50-F53.xx, F59-F60.xx, F63-F66.xx, F68-F69.xx, F80-F82.xx, F84.xx, F88-F93.xx, F95.xx, F98-F99.xx
- Telehealth visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
Telehealth modifier: 95 or GT Telehealth POS: 02
FUM - Follow-up after Emergency Department visit for mental illness (FUM) - The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:
- The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
- The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).
The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUM Billing codes:
- Outpatient follow-up visits CPT: 90791-2, 90832-4, 90836-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510
- HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
- Mental illness diagnosis codes ICD-10:9x, F20-25.xx, F28-34. xx, F39-45.xx, F48.xx, F50-53.xx, F59-60.xx, F63-66.xx, F68-69.xx, F80-82.xx, F84.xx, F88-93.xx, F95.xx, F98-99.xx
- Intentional self-harm diagnosis codes ICD-10 example:92XA
- Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
- Telehealth modifier: 95 or GT
- Telehealth modifier POS: 02
FUA - Follow-up after Emergency Department visit for alcohol and other drug abuse or dependence (FUA) - The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD.
Two rates are reported:
- The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
- The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).
The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUA Billing codes:
- Initiation, engagement and treatment follow-up visits CPT: 98960-2, 99078, 99201-5, 99211-5, 99241-5, 99341-50, 99384-7, 99394-7, 99401-4, 99408-9 99411-2, 99483, 99510
Alcohol counseling or other follow-up visits CPT: 99408-9 HCPCS: G0396-7, G0443, H0005, H0007, H0016, H0022, H0050, H2035-6, T1006, T1012 AOD
- Medication treatment HCPCS: G2067-77, G2080, G2086-7, H0020, H0033, J0570, J0571-5, J2315, Q9991-2, S0109
- Substance use disorder diagnosis codes ICD-10: F10-16.xx, F18-19.xx
- Telehealth modifier: 95 or GT
- Telephone visits: 98966 - 98968, 99441- 99443
- Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99408-99409, 98960-98962
- Telehealth modifier POS: 02
FUI – Follow-up after high-intensity care for substance use disorder (FUI) - The percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:
- The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
- The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.
FUI Billing codes:
- Opioid abuse and dependence ICD-10:10; F11.120; F11.121; F11.122; F11.129
- Other drug abuse and dependence ICD-10:10; F12.120; F12.121; F12.122; F12.129
- Alcohol abuse and dependence ICD-10:10; F10.120; F10.121; F10.14; F10.150
- Telephone visits CPT: 98966-98968; 99411-99443
- Online assessments CPT: 98969-98972; 99421-99423; 99444; 99458
- IET stand alone visits CPT: 98960-98962; 99201-99205; 99211-99215
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 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.
Medical policy updates
Revised Medical Policies Effective 02-18-2021
(The following policies were revised to expand medical necessity indications or criteria.)
- SURG.00121 - Transcatheter Heart Valve Procedures
- SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
New Medical Policy Effective 04-01-2021
(The policy below is new.)
- GENE.00056 - Gene Expression Profiling for Bladder Cancer [Note: CPT codes 0012M and 0013M moved from LAB.00011 Analysis of Proteomic Patterns
Revised Medical Policies Effective 04-01-2021
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- OR-PR.00003 – Microprocessor Controlled Lower Limb Prosthesis
- OR-PR.00005 - Upper Extremity Myoelectric Orthoses
- SURG.00007 – Vigus Nerve Stimulation
Revised Medical Policies Effective 04-01-2021
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- GENE.00049 - Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy) [Note: Moved CPT code 0229U to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
- GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- LAB.00011 - Analysis of Proteomic Patterns [Note: Moved CPT codes 0012M and 0013M to GENE.00056 Gene Expression Profiling for Bladder Cancer].SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
Revised Medical Policy Effective 04-07-2021
(The following policy was revised to expand medical necessity indications or criteria.)
- MED.00087 - Optical Detection for Screening and Identification of Cervical Cancer
Revised Medical Policies Effective 04-07-2021
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ANC.00007 - Cosmetic and Reconstructive Services: Skin Related
- ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
- DME.00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
- DME.00032 - Automated External Defibrillators for Home Use
- DME.00041 - Low Intensity Therapeutic Ultrasound
- GENE.00009 - Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
- GENE.00038 - Genetic Testing for Statin-Induced Myopathy
- GENE.00050 - Gene Expression Profiling for Coronary Artery Disease
- GENE.00054 - Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
- LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00015 - Detection of Circulating Tumor Cells
- LAB.00025 - Topographic Genotyping
- MED.00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
- MED.00024 - Adoptive Immunotherapy and Cellular Therapy
- MED.00053 - Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
- MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00059 - Idiopathic Environmental Illness (IEI)
- MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
- MED.00102 - Ultrafiltration in Decompensated Heart Failure
- MED.00104 - Non-Invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
- MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00111 - Intracardiac Ischemia Monitoring
- MED.00112 - Autonomic Testing
- MED.00118 - Continuous Monitoring of Intraocular Pressure
- MED.00120 - Gene Therapy for Ocular Conditions
- MED.00125 - Biofeedback and Neurofeedback
- MED.00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
- OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
- RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification
- RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
- RAD.00044 - Magnetic Resonance Neurography
- RAD.00052 - Positional MRI
- RAD.00059 - Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
- SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00032 - Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
- SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
- SURG.00053 - Unicondylar Interpositional Spacer
- SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
- SURG.00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses
- SURG.00070 - Photocoagulation of Macular Drusen
- SURG.00072 - Lysis of Epidural Adhesions
- SURG.00075 - Intervertebral Stabilization Devices
- SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation
- SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
- SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00107 - Prostate Saturation Biopsy
- SURG.00113 - Artificial Retinal Devices
- SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
- SURG.00127 - Sacroiliac Joint Fusion
- SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer
- SURG.00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
- SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
- SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
- SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
- SURG.00150 - Leadless Pacemaker
- SURG.00151 - Balloon Dilation of Eustachian Tubes
- SURG.00152 - Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
- SURG.00154 - Microsurgical Procedures for the Treatment of Lymphedema
- TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation
- TRANS.00013 - Small Bowel, Small Bowel/Liver and Multivisceral Transplantation
- TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
- TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Archived Medical Policy Effective 04-07-2021
(The following policy has been archived.)
- MED.00077 - In-Vivo Analysis of Gastrointestinal Lesions
Archived Medical Policies Effective 04-07-2021
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- GENE.00007 - Cardiac Ion Channel Genetic Testing [Note: Content transferred to CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions]
- GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment [Note: Content transferred to CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment]
- GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy) [Note: Content transferred to CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions]
Archived Medical Policy Effective 06-25-2021
(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)
- SURG.00022 - Lung Volume Reduction Surgery [Note: Content transferred to CG-SURG-110 Lung Volume Reduction Surgery
New Medical Policies Effective 07-01-2021
(The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- GENE.00056 - Gene Expression Profiling for Bladder Cancer
- LAB.00039 - Pooled Antibiotic Sensitivity Testing
Revised Medical Policy Effective 07-01-2021
(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
New Medical Policy Effective 07-01-2021
(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.)
- TRANS.00037 - Uterine Transplantation
Revised Medical Policy Effective 07-03-2021
(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
New Medical Policies Effective 07-17-2021
(The policies below were 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.00038 - Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
- SURG.00159 - Focal Laser Ablation for the Treatment of Prostate Cancer
Clinical guideline updates
Revised Clinical Guideline Effective 02-18-2021
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
Archived Clinical Guidelines Effective 04-01-2021
(The following guidelines have been archived and their content has been transferred to an existing Clinical UM Guideline.)
- CG-GENE-02 - Analysis of RAS Status [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]
- CG-GENE-03 - BRAF Mutation Analysis [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]
- CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]
- CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]
Revised Clinical Guideline Effective 04-01-2021
(The following adopted guideline was reviewed and had no significant changes to the policy position or criteria.)
- CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management [Note: Content from CG-GENE-02, GC-GENE-03, CG-GENE-12, and CG-GENE-20 transferred to this clinical UM guideline. CPT code 0229U moved from GENE.00049 Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy)]
Revised Clinical Guideline Effective 04-01-2021
(The following adopted guideline was updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
Adopted Clinical Guidelines Effective 04-07-2021
(The following guidelines were previously medical policies and have been adopted and have no significant changes.)
- CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment [Note: Content moved from GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment]
- CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions [Note: Content moved from GENE.00007 Cardiac Ion Channel Genetic Testing and GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)]
Revised Clinical Guidelines Effective 04-07-2021
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-MED-26 - Neonatal Levels of Care
- CG-SURG-71 - Reduction Mammoplasty
- CG-SURG-97 - Cardioverter Defibrillators
- CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
Revised Clinical Guidelines Effective 04-07-2021
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-DME-06 - Pneumatic Compression Devices for Lymphedema
- CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
- CG-GENE-07 - BCR-ABL Mutation Analysis
- CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
- CG-GENE-09 - Genetic Testing for CHARGE Syndrome
- CG-GENE-16 - BRCA Genetic Testing
- CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
- CG-MED-88 - Preimplantation Genetic Diagnosis Testing
- CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- CG-SURG-09 - Temporomandibular Disorders
- CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery
- CG-SURG-99 - Panniculectomy and Abdominoplasty
- CG-SURG-104 - Intraoperative Neurophysiological Monitoring
- CG-TRANS-02 - Kidney Transplantation
Revised Clinical Guidelines Effective 04-17-2021
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-MED-68 - Therapeutic Apheresis
- CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
Revised Clinical Guidelines Effective 07-01-2021
(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.)
Revised Clinical Guidelines Effective 07-17-2021
(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-DME-06 - Pneumatic Compression Devices for Lymphedema
- CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective July 1, 2021, we will upgrade to the 25th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive. Please note: The Behavioral Health guideline changes and Behavioral Health customization for the 25th edition only apply to the NY National Integrated Health Model accounts.
Goal Length of Stay (GLOS) for Inpatient & Surgical Care (ISC)
Guideline
|
MCG Code
|
24th Edition GLOS
|
25th Edition GLOS
|
Aortic Coarctation, Angioplasty
|
S-152
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
Cardiac Septal Defect: Atrial, Transcatheter Closure
|
W0016
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
Esophageal Diverticulectomy, Endoscopic
|
S-445
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
Gastrectomy, Partial - Billroth I or II
|
S-510
|
4 or 6 days postoperative
|
5 days postoperative
|
Hernia Repair (Non-Hiatal)
|
S-1305
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
Pancreatectomy
|
S-1200
|
5 or 7 days postoperative
|
6 days postoperative
|
Pyloroplasty and Vagotomy
|
S-990
|
4 or 6 days postoperative
|
4 days postoperative
|
Cervical Laminectomy
|
W0097
|
2 days postoperative
|
Ambulatory or 2 days postoperative
|
Lumbar Diskectomy, Foraminotomy, or Laminotomy
|
W0091
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
Removal of Posterior Spinal Instrumentation
|
S-530
|
1 day postoperative
|
Ambulatory or 1 day postoperative
|
Shoulder Hemiarthroplasty
|
W0138
|
1 day postoperative
|
Ambulatory or 1 day postoperative
|
Spine, Scoliosis, Posterior Instrumentation, Pediatric
|
W0156
|
4 days postoperative
|
3 days postoperative
|
Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent
|
S-190
|
5 or 6 days postoperative
|
5 days postoperative
|
Prostatectomy, Transurethral Resection (TURP)
|
S-970
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
Urethroplasty
|
S-1172
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)
Body System
|
Guideline Title
|
MCG - Code
|
Withdrawal Management
|
Withdrawal Management, Adult: Inpatient Care
|
B-031-IP
|
Withdrawal Management
|
Withdrawal Management, Adult: Intensive Outpatient Program
|
B-031-IOP
|
Withdrawal Management
|
Withdrawal Management, Adult: Outpatient Care
|
B-031-AOP
|
Withdrawal Management
|
Withdrawal Management, Adult: Partial Hospital Program
|
B-031-PHP
|
Withdrawal Management
|
Withdrawal Management, Adult: Residential Care
|
B-031-RES
|
Cardiology
|
Hypertension
|
M-5197
|
Cardiology
|
Peripheral Vascular Disease (PVD)
|
M-7087
|
Nephrology
|
Rhabdomyolysis
|
M-7095
|
Nephrology
|
Encephalopathy
|
M-7100
|
Thoracic Surgery
|
Rib Fracture
|
M-5545
|
Empire customizations to MCG care guideline 25th edition
Effective July 1, 2021, the following MCG care guideline 25th edition customizations will be implemented.
- Transcranial Magnetic Stimulation, W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:
- Need for acute TMS treatment, up to 6 weeks
- Acute treatment course needed as indicated by (a) Initial course of treatment for major depressive disorder (severe), or (b) Relapse of symptoms after remission
- Continuation of acute treatment, up to 6 months
- TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
- Maintenance TMS treatment
- Continuation of acute TMS treatment for longer than 6 months
- TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.
To view a detailed summary of customizations click on this link, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.
For questions, please contact the provider service number on the back of the member's ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. CPT Code E1399 is not an appropriate billable code for CPAP/APAP/BiPAP. When Providers are requesting CPAP/APAP/BIPAP, please do NOT use a NOC code, use the specific appropriate code for each of these devices. E1399 will no longer be part of AIM’s Sleep Therapy program as of 4/1/21 and should not be submitted to AIM for review for CPAP/APAP/BiPAP.
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 April 1, 2021 Empire BlueCross BlueShield (“Empire”) will be implementing revised claims editing logic tied to Excludes 1 notes from ICD-10-CM 2020 coding guidelines. To help ensure the accurate processing of claims, use ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the Category level that a code can be billed with another range of codes, it is imperative to look for Excludes 1 notes that may prohibit billing a specific code combination.
For assistance in determining proper coding guidance, the following site should be helpful: https://www.cdc.gov/nchs/icd/icd10cm.htm
One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 notes. An Excludes 1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes 1 note. These notes appear below the affected codes – if the note appears under the Category (first three characters of a code), it applies to the entire series of codes within that category. If the Excludes 1 note appears beneath a specific code (3, 4, 5, 6 or 7 characters in length) then it applies only to that specific code
- Reporting Z01.419 with Z12.4
- Z01.41X (encounter GYN exam w/out abnormal findings) has an Excludes 1 note below that includes Z12.4.
- Z12.4 (encounter for screening malignant neoplasm cervix)
- Reporting Z79.891 with F11.2X
- Z79.891 (long-term use of Opiates) has an Excludes 1 note after it for F11.2X. F11.2X (Opioid dependence)
- Reporting M54.2 with M50.XX
- M54.2 (Cervicalgia) has an Excludes 1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder)
- Reporting M54.5 with S39.012X and/or M54.4x
- M54.5 (low back pain) has an Excludes 1 note below it which includes; S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain) M51.2X (lumbago due to intervertebral disc disorder)
- Reporting J03.XX with J02.XX, J35.1, J36, J02.9
- J03.XX (Acute tonsillitis) has an Excludes 1 note below it which includes; J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), J36 (Peritonsillar abscess)
- Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, A59.00
- N89 (Other inflammatory disorders of the vagina) has an Excludes 1 note below the category for
- R87.62X (abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia),
- R87.623 (HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis),
- A59.00 (trichomonal leukorrhea)
Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM codebook to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process as to why the billed diagnoses codes are appropriately used together.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This is an update to the article published in the March 2021 edition of Provider News regarding Site of Care medical necessity reviews for long-acting colony-stimulating factors.
The effective date has been moved from June 1, 2021 to August 1, 2021.
Please see below for the complete updated notice.
Effective with dates of service on or after August 1, 2021, medical necessity review of the site of care is required for the following long-acting colony-stimulating factors for oncology indications for Empire BlueCross BlueShield (“Empire”) Commercial plan members.
- Neulasta® & Neulasta Onpro® (pegfilgrastim)
- Fulphila® (pegfilgrastim-jmdb)
- Udenyca® (pegfilgrastim-cbqv)
- Ziextenzo® (pegfilgrastim-bmez)
- Nyvepria™ (pegfilgrastim-apgf)
The review will be administered by AIM Specialty Health® (AIM).
AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit our Medical Policies and Clinical Guidelines webpage. You may contact AIM to request a peer-to-peer discussion before or after the determination.
The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.
Submit a request for review
Starting July 19, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after August 1, 2021 to AIM in one of the following ways:
- Access AIM 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 review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Empire members on the Clinical criteria webpage.
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the member’s ID card.
Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “site of care.”
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Having the common goal of reaching all Latinos in the US, Anthem, Inc., the Beckman Research Institute of City of Hope, the National Hispanic Medical Association, and Pfizer, Inc., announce the launch of Tomando Acción por Nuestra Salud/Taking Action for Our Health, a free interactive bilingual website aimed at eliminating health disparities in the Latino community. The website encourages preventive health screenings for cancer, emotional health, heart health, and prediabetes. It also provides tools to help people care for the emotional health of their families and themselves in the language of their preference.
The interactive website highlights the importance of health screenings, addresses barriers and provides information on access to low and no cost healthcare services in the community. The easy to use website, guides participants through four programs where they can learn about risk factors, take action to get screened, monitor their progress, and share their results with their doctors, health care teams or family and friends to let them know they are taking steps to protect their health and help encourage others to participate as well.
The website is not exclusive for Empire BlueCross BlueShield members. Health care providers are encouraged to share the website with all their Latino patients.
The website identifies four major targets of undue poor health outcomes for Latinos. In response, Tomando Acción por Nuestra Salud/Taking Action for Our Health strives to help increase cancer screening, screening for depression/anxiety-risk, heart diseases and prediabetes and provides tools to address emotional health. The website includes a 4-part workshop series “Comparted el Café y el Chocolate/Coffee and Chocolate” to help people care for the emotional health of their family and themselves. This is a program, specifically for Hispanics, that uses a holistic approach to emotional stability. It builds on cultural strengths to balance four key items—community, body, mind, and spirit.
To access Tomando Acción por Nuestra Salud/Taking Action for Our Health visit: Taking Action for Our Health.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Reveleer is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers and ask that you respond to the detailed requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe. Reveleer will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary). We ask that you please promptly comply within five (5) business days of the record requests. If you have any questions, you can reach a Reveleer representative by calling 855-454-6182 or contact Ify Ifezulike with Blue Cross Blue Shield Federal Employee Program at (202) 626-4839.
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. Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.
The following clinical criteria documents were endorsed at the February 19, 2021 clinical criteria meeting. To access the clinical criteria information please click here.
New clinical criteria effective February 25, 2021
The following clinical criteria are new.
- ING-CC-0186 Margenza (margetuximab-cmkb)
- ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
Revised clinical criteria effective February 25, 2021
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0028 Benlysta (belimumab)
- ING-CC-0094 Pemetrexed Agents (Alimta, Pemfexy)
Revised clinical criteria effective February 25, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
- ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy
New clinical criteria effective March 16, 2021
The following clinical criteria are new.
- ING-CC-0189 Amondys 45 (casimersen)
- ING-CC-0190 Nulibry (fosdenopterin)
Revised clinical criteria effective March 23, 2021
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0033 Xolair (omalizumab)
- ING-CC-0043 Monoclonal Antibodies to Interleukin-5
- ING-CC-0099 Abraxane (paclitaxel protein-bound)
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
Revised clinical criteria effective March 23, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0085 Actimmune (interferon gamma-1b)
- ING-CC-0088 Elzonris (tagraxofusp-erzs)
- ING-CC-0089 Mozobil (plerixafor)
- ING-CC-0090 Ixempra (ixabepilone)
- ING-CC-0091 Lartruvo (olaratumab)
- ING-CC-0096 Asparagine Specific Enzymes
- ING-CC-0103 Faslodex (fulvestrant)
- ING-CC-0108 Halaven (eribulin)
- ING-CC-0109 Zaltrap (ziv-aflibercept)
- ING-CC-0110 Perjeta (pertuzumab)
- ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
- ING-CC-0113 Sylvant (siltuximab)
- ING-CC-0117 Empliciti (elotuzumab)
- ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Zevalin)
- ING-CC-0120 Kyprolis (carfilzomib)
- ING-CC-0122 Arzerra (ofatumumab)
- ING-CC-0126 Blincyto (blinatumomab)
- ING-CC-0129 Bavencio (avelumab) injection
- ING-CC-0130 Imfinzi (durvalumab)
- ING-CC-0131 Besponsa (inotuzumab ozogamicin)
- ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
- ING-CC-0135 Melanoma Vaccines
- ING-CC-0140 Zulresso (brexanolone)
- ING-CC-0156 Reblozyl (luspatercept)
- ING-CC-0160 Vyepti (eptinezumab-jjmr)
- ING-CC-0164 Jelmyto (mitomycin gel)
Revised clinical criteria effective April 1, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0027 Denosumab Agents
- ING-CC-0121 Gazyva (obinutuzumab)
New clinical criteria effective July 1, 2021
The following clinical criteria is new.
- ING-CC-0188 Imcivree (setmelanotide)
Revised clinical criteria effective July 1, 2021
The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0028 Benlysta (belimumab)
- ING-CC-0033 Xolair (omalizumab)
- ING-CC-0034 Hereditary Angioedema Agents
- ING-CC-0043 Monoclonal Antibodies to Interleukin-5
- ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
- ING-CC-0075 Rituximab agents for Non-Oncologic Indications
- ING-CC-0086 Spravato (esketamine) Nasal Spray
- ING-CC-0094 Pemetrexed Agents (Alimta, Pemfexy)
- ING-CC-0115 Kadcyla (ado-trastuzumab)
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0123 Cyramza (ramucirumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0157 Padcev (enfortumab vedotin-ejfv)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Prior authorization updates
Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
To access the Clinical Criteria information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
*ING-CC-0027
|
J0897
|
Xgeva
|
Quantity Limit Updates
Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
To access the Clinical Criteria information please click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
*ING-CC-0027
|
J0897
|
Xgeva
|
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. On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.
Visit clinical criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of clinical criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The clinical criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
April 8, 2021
|
ING-CC-0185*
|
Oxlumo (lumasiran)
|
New
|
April 8, 2021
|
ING-CC-0184*
|
Danyelza (naxitamab-gqgk)
|
New
|
April 8, 2021
|
ING-CC-0154
|
Givlaari (givosiran)
|
Revised
|
April 8, 2021
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
April 8, 2021
|
ING-CC-0002
|
Colony Stimulating Factor Agents
|
Revised
|
April 8, 2021
|
ING-CC-0032*
|
Botulinum Toxin
|
Revised
|
April 8, 2021
|
ING-CC-0015
|
Infertility and HCG Agents
|
Revised
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On June 18, 2020, August 21, 2020, and November 20, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.
Visit clinical criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of clinical criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Please note: The clinical criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
March 26, 2021
|
ING-CC-0183*
|
Sogroya (somapacitan-beco)
|
New
|
March 26, 2021
|
ING-CC-0148*
|
Agents for Hemophilia B
|
Revised
|
March 26, 2021
|
ING-CC-0149*
|
Select Clotting Agents for Bleeding Disorders
|
Revised
|
March 26, 2021
|
ING-CC-0065
|
Agents for Hemophilia A and von Willebrand Disease
|
Revised
|
March 26, 2021
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
March 26, 2021
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
Revised
|
March 26, 2021
|
ING-CC-0121*
|
Gazyva (obinutuzumab)
|
Revised
|
March 26, 2021
|
ING-CC-0048 *
|
Spinraza (nusinersen)
|
Revised
|
March 26, 2021
|
ING-CC-0002*
|
Colony Stimulating Factor Agents
|
Revised
|
March 26, 2021
|
ING-CC-0034*
|
Hereditary Angioedema Agents
|
Revised
|
March 26, 2021
|
ING-CC-0041*
|
Complement Inhibitors
|
Revised
|
March 26, 2021
|
ING-CC-0071*
|
Entyvio (vedolizumab)
|
Revised
|
March 26, 2021
|
ING-CC-0064*
|
Interleukin-1 Inhibitors
|
Revised
|
March 26, 2021
|
ING-CC-0042*
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
March 26, 2021
|
ING-CC-0066*
|
Monoclonal Antibodies to Interleukin-6
|
Revised
|
March 26, 2021
|
ING-CC-0050*
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
March 26, 2021
|
ING-CC-0078*
|
Orencia (abatacept)
|
Revised
|
March 26, 2021
|
ING-CC-0063*
|
Stelara (ustekinumab)
|
Revised
|
March 26, 2021
|
ING-CC-0062*
|
Tumor Necrosis Factor Antagonists
|
Revised
|
March 26, 2021
|
ING-CC-0003*
|
Immunoglobulins
|
Revised
|
March 26, 2021
|
ING-CC-0039*
|
GamaSTAN [immune globulin (human)]
|
Revised
|
March 26, 2021
|
ING-CC-0053
|
Injectable Hydroxyprogesterone for Prevention of Preterm Birth
|
Revised
|
March 26, 2021
|
ING-CC-0073*
|
Alpha-1 Proteinase Inhibitor Therapy
|
Revised
|
March 26, 2021
|
ING-CC-0075
|
Rituximab Agents for Non-Oncologic Indications
|
Revised
|
March 26, 2021
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
March 26, 2021
|
ING-CC-0027*
|
Denosumab Agents
|
Revised
|
March 26, 2021
|
ING-CC-0019*
|
Zoledronic Acid Agents (Reclast, Zometa)
|
Revised
|
March 26, 2021
|
ING-CC-0011*
|
Ocrevus (ocrelizumab)
|
Revised
|
March 26, 2021
|
*ING-CC-0174*
|
Kesimpta (ofatumumab)
|
Revised
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (Empire) is committed to be a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to better healthcare experiences for consumers.
Effective for dates of service on or after July 1, 2021, providers for our Medicare Advantage plan members covered by Empire will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications, listed below. Reviews for these oncology drugs will continue to be administered by the reviewing company, either AIM Specialty Health®* or IngenioRx. *
Providers will be asked whether they will accept the dose reduction at the initial review point in the prior authorization process. Within the provider portal, a pop-up question will appear related to dose reduction. If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning. For requests made outside of the provider portal (for example, called-in or faxed-in prior authorization requests), the same questions will be asked by the registered nurse or medical director who is reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.
The dose reduction questions will appear only if the originally requested dose is within 10% of the nearest whole vial. This threshold is based on current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) that it is appropriate to consider dose rounding within 10%. HOPA recommendations can be found here.
The Voluntary Dose Reduction Program only applies to specific oncology drugs, listed below. Providers can view prior authorization requirements for Empire members on the Medical Policy and Clinical Utilization Management Guidelines page at https://www.empireblue.com/medicareprovider.
Drug name
|
HCPCS code
|
Drug name
|
HCPCS code
|
Abraxane (paclitaxel protein-bound)
|
J9264
|
Istodax (romidepsin)
|
J9315
|
Actimmune (interferon gamma-1B)
|
J9216
|
Ixempra (ixabepilone)
|
J9207
|
Adcetris (brentuximab vedotin)
|
J9042
|
Jevtana (cabazitaxel)
|
J9043
|
Alimta (pemetrexed)
|
J9305
|
Kadcyla (ado-trastuzumab emtansine)
|
J9354
|
Asparlas (calaspargase pegol-mknl)
|
J9118
|
Keytruda (pembrolizumab)
|
J9271
|
Avastin (bevacizumab)
|
J9035
|
Kyprolis (carfilzomib)
|
J9047
|
Bendeka (bendamustine)
|
J9034
|
Lartruvo (olaratumab)
|
J9285
|
Besponsa (inotuzumab ozogamicin)
|
J9229
|
Lumoxiti (moxetumomab pasudotox-tdfk)
|
J9313
|
Blincyto (blinatumomab)
|
J9039
|
Mylotarg (gemtuzumab ozogamicin)
|
J9203
|
Cyramza (ramucirumab)
|
J9308
|
Neupogen (filgrastim)
|
J1442
|
Darzalex (daratumumab)
|
J9145
|
Oncaspar (pegaspargase)
|
J9266
|
Doxorubicin liposomal
|
Q2050
|
Opdivo (nivolumab)
|
J9299
|
Elzonris (tagraxofusp-erzs)
|
J9269
|
Padcev (enfortumab vedotin-ejfv)
|
J9177
|
Empliciti (elotuzumab)
|
J9176
|
Polivy (polatuzumab vedotin-piiq)
|
J9309
|
Enhertu (fam-trastuzumab deruxtecan-nxki)
|
J9358
|
Rituxan (rituximab)
|
J9312
|
Erbitux (cetuximab)
|
J9055
|
Sarclisa (isatuximab-irfc)
|
J9999
|
Erwinase (asparginase)
|
J9019
|
Sylvant (siltuximab)
|
J2860
|
Ethyol (amifostine)
|
J0207
|
Treanda (bendamustine)
|
J9033
|
Granix (tbo-filgrastim)
|
J1447
|
Vectibix (panitumumab)
|
J9303
|
Halaven (eribulin mesylate)
|
J9179
|
Yervoy (ipilimumab)
|
J9228
|
Herceptin (trastuzumab)
|
J9355
|
Zaltrap (ziv-aflibercept)
|
J9400
|
Imfinzi (durvalumab)
|
J9173
|
|
|
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Note: In some plans, dose reduction to nearest whole vial or waste reduction may be the term used in benefit plans, provider contracts or other materials instead of or in addition to dose reduction to nearest whole vial. In some plans, these terms may be used interchangeably. For simplicity, we have uses dose reduction (to nearest whole vial).
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Welcome to the 2021 In-Office Assessment (IOA) program. The IOA program is designed to help providers ensure that all active conditions are continuously being addressed and documented to the highest level of specificity for all Medicare Advantage plan patients of providers participating in the program. This program is designed to help improve all patient quality of care (preventive medicine screening, managing chronic illness and prescription management), as well as care for older adults when generated for a Special Needs Plan member.
If you are interested in learning about the electronic modalities available, please contact your representative or the Optum* Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.
Success stories
Below are some achievements that Empire BlueCross BlueShield (Empire) was able to accomplish with provider groups through the IOA program:
- As a result of leveraging different types of resources offered by the IOA program (for example, technology), providers’ offices were able to see an increase in staff productivity.
- Providers who have taken advantage of the IOA program resources have seen an increase in their documentation and coding accuracy.
COVID-19 update
Empire knows this is a difficult time for everyone, as the situation continues to evolve each day. Empire has considered the severity of the situation and is following CDC Guidelines. For the IOA program, all nonessential personal is required to work with provider groups telephonically/electronically until further notice.
Empire continues to evaluate the situation and guidelines and will keep you notified of any changes. If you have any questions or concerns about the IOA program and COVID-19 updates, please call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.
Dates and tips to remember:
- To review their population as soon as possible, Empire strongly encourages participating providers to deliver and continually maintain proper care management, as well as care coordination of their patient population. This will further ensure the current and active conditions that impact patient care, treatment and/or management are continually addressed.
- At the conclusion of each office visit with the patient, providers participating in the IOA program are asked to complete and return a patient assessment. The assessment should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2021 version of the assessment for encounters that take place on or before December 31, 2021; Empire will accept the 2021 version of the assessment for 2021 encounters until midnight January 31, 2022.
- If not already submitted, participating providers are required to submit an Account Setup Form, W-9 and completed direct deposit enrollment by March 31, 2022. Participating providers should call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time, if they have any questions regarding this requirement. Failure to comply with this requirement will result in forfeiture of the provider payment for submitted 2021 assessments, if applicable.
Questions
If you have questions about this communication or the IOA program, please contact your representative or the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Does your practice offer telehealth services? Let us know!
Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.
We encourage providers to use the online Provider Maintenance Form to notify us about your telehealth services, and we will add a telehealth indicator to your online provider directory profile.
Visit https://www.empireblue.com/medicareprovider to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |