As part of our commitment to provide you with the latest clinical information, we have posted a VBAC shared decision making aid to our provider portal. This is a tool for you to discuss with your patients to aid in making a decision regarding their treatment options.   This has been reviewed and certified by the Washington Health Care Authority (HCA) and is available on our website.  To access the aid, go to empireblue.com/provider/ Select “Find Resources in New York” >Provider Home > > Health and Wellness > Practice Guidelines > Shared Decision-Making Aid.

Beginning with dates of service on and after November 1, 2018, Empire will expand precertification requirements to include upper gastrointestinal (GI) endoscopy, also referred to as esophagogastroduodenoscopy (EGD).  AIM Specialty Health® (AIM), a separate company, will administer this EGD review on behalf of Empire.

EGD procedures will be reviewed against clinical guideline CG-MED-59, Upper Gastrointestinal Endoscopy, for clinical appropriateness and to help ensure care aligns with established evidence-based medicine. Please note, procedures performed in an inpatient or observation setting, or on an emergent basis will not be reviewed under CG-MED-59.

A complete list of EGD CPT codes requiring precertification is available on the AIM Surgical Procedures website.

Submit a request for review

Starting October 17, 2018, ordering providers may submit precertification requests for dates of service November 1, 2018 and after 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 should continue to verify eligibility and benefits for all members prior to rendering services.

For questions, please contact the Provider Service number on the back of the ID card.

Effective November 1, 2018, Empire will update network fee schedules.   

Although this update will result in an overall net increase of our physician network fees, the actual impact to any particular physician will depend on the codes most frequently billed by that physician.

The complete updated fee schedule will be available on our Physician Online Services at www.empireblue.com upon their effective date of November 1, 2018.

Effective for professional claims (CMS-1500) processed on or after November 18, 2018, Empire will enhance our editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT, HCPCS Level II, and International Classification of Diseases 10 (ICD-10).  As a result, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day. This enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

Below are examples of claim edits that will be automated:

• Accurate reporting of modifiers, including LT, RT, 54, 55, 56, 62,76, 77, 78, 79, 80, 81, 82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.
• Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.
• Assessing whether services considered once in a lifetime have been billed more than once.
• Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together. 

By the end of 2018, Empire members will begin receiving a new explanation of benefits (EOB) that is designed to help members better understand their health care benefits and out-of-pocket expenses. The new design will look more like a health care summary. EOBs will continue to include important information about services rendered, the amount paid to the provider, and the member out-of-pocket expense.

The new EOB will also include:

• Ways members can save on health care expenses
• A preventive care checklist, sharing important screenings that were missed
• A summary of the member’s most recent claims

Learn more about our newly designed EOB.

To better assess measures of quality for our members, Empire will begin requiring documentation of a newborn’s gestational age at the time of delivery for all physician delivery claims.

Beginning with dates of service on and after November 1, 2018, all professional delivery claims (59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620 and 59622) will require an ICD-10 Z3A code indicating the newborn’s gestational age at the time of delivery. If the code is not found on the claim, the claim will be denied with the following reason:  “Delivery diagnoses incomplete without report of pregnancy weeks of gestation. You may resubmit the corrected claim with the appropriate ICD-10 code for payment.”

Beginning August 20, 2018, Interactive Care Reviewer (ICR) will be your exclusive online tool for initiating and checking the status for many of your inpatient medical authorizations and inpatient and outpatient behavioral health authorizations for Empire local market membership. Coming later in 2018, ICR will be available for medical outpatient authorizations, National Account membership, Medicaid and Medicare Advantage membership. Look for announcements of these additions in upcoming communications.

How do I gain access to the ICR?

You can access our ICR tool via the Availity Portal. If your organization has not yet registered for Availity, go to www.availity.com and select Register in the upper right-hand corner of the page.

If your organization already has access to Availity, your Availity administrator can grant you access to “authorization and referral request” for submission capability and “authorization and referral inquiry” for inquiry capability.

You can then find our tool under Patient Registration | Authorizations & Referrals. Then select the Authorizations or Authorization/Referral Inquiry option as appropriate.

Is ICR training available?

You can attend one of the ICR monthly webinars. Register for the next August webinar HERE.

Who can providers contact with questions?

For questions regarding our ICR, please contact your local Provider Relations representative. For questions on accessing our tool via Availity, call Availity Client Services at [1-800-AVAILITY (1-800-282-4548)]. Availity Client Services is available [Monday-Friday, 8 a.m.-7 p.m. Eastern time (excluding holidays)] to answer your registration questions.

What benefits/efficiencies does the ICR provide?

• You are automatically routed to our ICR. Once the ICR is available, when you go to Authorizations in the Availity Web Portal, you are automatically routed to the ICR in order to begin your prior authorization request.
• You can determine if prior authorization is needed. For most requests, when you enter patient, service and provider details, you will receive a message indicating whether or not review is required.
• You will have inquiry capability. Ordering and servicing physicians and facilities can locate information on preauthorization requests for those they are affiliated with; this includes requests previously submitted via phone, fax, ICR or another online tool (for example, AIM Specialty Health®).
• The ICR is easy to use. You can submit outpatient and inpatient requests for services online using the same, easy-to-use functionality.
• The ICR reduces the need to fax. The ICR allows text detail as well as images to be submitted along with the request. Therefore, you can submit requests online and reduce the need to fax medical records.
• There is no additional cost to you. The ICR is a no-cost solution that’s easy to learn and even easier to use.
• You can access the ICR tool almost anywhere. You can submit your requests from any computer with internet access. (Note: We recommend you use Internet Explorer 11, Chrome, Firefox or Safari for optimal viewing.)
• You receive a comprehensive view of all your preauthorization requests. You have a complete view of all the utilization management requests you submitted online, including the status of your requests and specific views that provide case updates and a copy of associated letters.

*Coming later in 2018 – ICR will be available for Medical outpatient authorizations, National Account membership, Medicaid and Medicare Advantage membership. Look for announcements of these additions in upcoming communications.

Empire has partnered with Availity to become our designated EDI Gateway.  The effort is currently underway, and both are committed to providing transparency for our customers.

All EDI submissions currently received today via the Empire EDI Gateway are all now available on the Availity EDI Gateway.  There is no impact to the provider’s participation status with Empire and no impact on how claims adjudicate.

If you are connected to Availity you can use your same connection for your EDI submissions.

If you are using another clearinghouse, contact your clearinghouse to validate their transition dates. If your clearinghouse notifies you of changes regarding connectivity, workflow, or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Your organization can register with Availity to submit the following transactions:

837- Institutional 837- Professional 837- Dental 835- Electronic Remittance Advice 276/277- Claim Status – real-time 270/271- Eligibility – real-time

Next steps:

• Empire and Availity will continue to communicate and provide assistance with this transition going forward.
• Availity will be working directly with all trading partners.
• We do recommend that you register with Availity for your EDI transmissions for a free fully subsidized option.            
•  

How to register with Availity:

• If your organization is not already registered with Availity you can go to www.availity.com, click REGISTER and then follow the steps to register.
• Look for emails, from Availity, containing your log in credentials.
• If your organization is already registered with Availity, you can log in and click My Providers | Enrollments Center if you need to complete new 835 enrollment or make changes.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-282-4548 Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time. 

Are you an Empire provider that needs help transitioning to using Availity’s Gateway solutions? Are you looking for SFTP or other batch upload options? If yes, check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session.

During this fast-paced hour, you’ll learn how to:

• Understand Availity’s EDI Gateway and Clearinghouse workflow
• Enroll for and manage 835 ERA delivery with Availity
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences, and more.
• Access and navigate the Availity EDI Guide.

Enrollment Information

1. Log in to the Availity Portal.
2. Click Help & Training | Get Trained.
3. In the Catalog, click Sessions.
4. Scroll through Your Calendar to view upcoming live events.

Tip: You can also search the ALC Catalog by a special keyword set up just for you. The keyword is song.

Schedule

Enroll for an upcoming webinar (and check back again later for additional dates and times).

• Monday, 8/20/2018, 3:00 p.m. to 4:00 p.m. Eastern time
• Thursday, 8/23/2018, 1:00 p.m. to 2:00 p.m. Eastern time
• Tuesday, 9/25/2018, 12:00 noon to 1:00 p.m. Eastern time
• Thursday, 9/27/2018, 3:00 p.m. to 4:00 p.m. Eastern time

Additional Training

You can search the Catalog by keyword to access live and on-demand training recommendations curated by Availity Learning especially to help you with this transition. The keyword is “song” for Empire.

As you know, Empire offers pregnant women several services and benefits through the Future Moms program. It is our goal to try to ensure all pregnant members are identified early in their pregnancy so they can take full advantage of the education, support, resources and incentives Empire provides throughout the prenatal and postpartum period.

We’ve partnered with Availity, the vendor supporting the Benefit Look-Up Tool you may currently use in your OB office, to send us information about newly identified pregnant women. This new process, including the HEDIS® Maternity Attestation form, helps connect patients with additional benefits as soon as possible. The reporting process includes a few simple steps.

How it works

When an Empire member of childbearing age visits the OB office, the office associate is prompted to answer the question “Is the member pregnant?” during the eligibility and benefits inquiry process. If the response is “yes,” the system asks about the due date, and a HEDIS Maternity Attestation form is generated for the OB office to complete. On this electronic form, providers are asked to provide other important information including the date of the first prenatal care visit, delivery date and postpartum visit date.

This new, user-friendly workflow generates timely information that aids members, providers and Empire in improving birth outcomes with early intervention.

We are working hard to support providers throughout New York in receiving necessary training for this new workflow. If you have specific questions regarding the new Availity maternity attestation process, please feel free to reach out to the Empire Customer Care Center at 1‑800‑407-4627  or 1-888-285-7801.

The Affordable Care Act (ACA) requires many health plans to cover recommended preventive care services without member cost sharing when the services are rendered by an in-network provider and/or facility. Screening colonoscopies (even when polyps are removed) are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT and ICD-10 codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.

The following services are covered with no member cost share:

• The colonoscopy screening procedure.
• Anesthesia charges when anesthesia is billed with the appropriate screening CPT code (even when polyps are removed).
• Other associated facility charges when the colonoscopy is billed with an appropriate screening diagnosis code.
• When polyps are removed during a screening colonoscopy - the removal, examination and analysis of the polyps.

In the instance where a screening colonoscopy starts out as screening but turns into a diagnostic procedure due to polyps being removed, Empire follows CPT guidelines for our Commercial members, not Medicare guidelines. The CPT® 2018 Professional Edition manual shares the following information regarding the billing of anesthesia for any screening colonoscopy, “Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings.”

We’ve heard it all our lives:  To be fair, you should treat everybody the same.  But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well.

The reality is burden of illness, premature death, and disability disproportionately affects certain populations.¹ MyDiversePatient.com features robust educational resources to help support you in addressing these disparities. 

You will find:

• CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

While there’s no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends…one patient at a time.

Accelerate your journey to becoming your patients’ trusted health care partner by visiting MyDiversePatient.com today.

[1] Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013.  Morbidity and Mortality Weekly Report. Vol 62(Suppl 3); p3.

Empire is working with Accordant Health Services to provide targeted disease management services for members with rare medical conditions, including:  

• Epilepsy (Seizures)
• Rheumatoid Arthritis (RA)
• Human Immunodeficiency Virus (HIV)
• Multiple Sclerosis (MS)
• Crohn's Disease (CD)
• Ulcerative Colitis (UC)
• Parkinson's Disease (PD)
• Systemic Lupus Erythematosus (SLE or Lupus)
• Myasthenia Gravis (MG)
• Sickle Cell Disease (SCD)
• Cystic Fibrosis (CF)
• Hemophilia
• Scleroderma
• Polymyositis
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
• Amyotrophic Lateral Sclerosis (ALS)
• Dermatomyositis
• Gaucher Disease

Members in your care who may benefit from additional outreach and information may receive letters or phone calls from AccordantCare and Empire. In the course of performing these activities, a nurse may contact you or your facility to obtain member information and/or AccordantCare may request medical information about Empire members. AccordantCare and Empire also will let you know of any health changes that may require your attention.

If you would like to refer a member to this program, please contact AccordantCare at:

Phone or Fax: 1-866-247-1150

Web: https://referral.accordant.com

Plan name: AnthemReferrals Password: ref1088Anthem

A key goal of Empire’s provider transparency efforts is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Enhanced Personal Health Care (EPHC) Program quality and/or cost information about the health care providers to which the PCPs refer their Attributed Members (the “Referral Providers”). If a Referral Provider is higher quality and/or lower cost, this component of the program should result in their getting more referrals from PCPs. The converse should be true if Referral Providers are lower quality and/or higher cost. Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost information so that they can better understand how their health care dollars are being spent. This will 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.

Cost Opportunity Report

• The Cost Opportunity Report is available for EPHC providers to access via Provider Care Management Solutions (PCMS).
• The report was created to help users quickly identify meaningful and actionable opportunities to optimize costs and help achieve shared savings targets within the EPHC Program.
• By providing a standard set of potential cost opportunity metrics, the Cost Opportunity Report can be used to help evaluate the relative success of providers within the EPHC Program.
• Metrics are selected based on size of financial opportunity, ability of PCPs to affect changes, mix of impacted service types, mix of utilization and unit price impact.
• Metrics are reviewed on a periodic basis and may be added, changed or removed.

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

As was previously communicated in the December 2017 provider newsletter, Empire has established a contractual relationship with Alliant Health Solutions to assist the organization in validating provider compliance with applicable reimbursement policies and identify instances of incorrect billing for behavioral health services.  Alliant has initiated the work and your compliance is required should you receive a request for information.  Alliant, is a behavioral health audit and review company, and will examine Empire outpatient behavioral health claims data.  Utilizing systematic sampling methodology and a broad range of algorithms, the audits and findings will be customized to support Empire’s expectations as outlined in the Empire Provider Manuals and related policies and procedures.  Alliant findings may result in provider audits and record reviews, education and other direct outreach. 

Empire members suffering from eating disorders have a new treatment option available to help support transitions of care and to prevent relapse.  Eating Disorder Recovery Specialists (EDRS), a Manhattan-based organization, is now providing in-home, on-campus, and community-based eating disorder treatment to Empire members.

Most patients with eating disorders do well while in structured treatment, yet many struggle with eating at home and in the community.  EDRS provides meal coaching and other therapeutic support, to ensure that treatment gains are maintained in the member’s usual environment, which can prevent the need for multiple treatment episodes.

EDRS’s services are available statewide, and can be accessed by calling 866-525-2766 or at www.edrs.com.

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

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

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

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

Beginning with dates of service on and after October 29, 2018, the following updates will apply to AIM Advanced Imaging Clinical Appropriateness Guidelines:                                                                                                                         

CT Chest guideline:

• Expanded list of diagnostic testing abnormalities that may be followed up with CT to include endoscopy, fluoroscopy, and ultrasound in addition to specific chest radiography findings
• Lengthening of timeframe required prior to imaging for chronic cough from 3 to 8 weeks, and more specifics of preliminary workup required prior to imaging
• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
• Allowance for use of imaging in the staging of malignancy prior to biopsy confirmation
• Allowance for imaging of suspected pulmonary embolism in pregnancy
• New criteria for appropriate imaging of chest wall mass

CT Angiography (CTA) Chest guideline:

• Allowance for imaging of suspected pulmonary embolism in pregnancy

CT Abdomen/CT Pelvis/CT Abdomen & Pelvis guideline:

• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging

MRI Chest guideline:

• Inclusion of imaging of suspected pectoralis muscle tear
• New criteria for appropriate imaging of chest wall mass

MRI Abdomen guideline:

• Addition of hemochromatosis as an indication for imaging in pediatric patients

Ordering and servicing providers may submit prior authorization requests 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.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com.

Additionally, you may access and download a copy of the current guidelines here.

Beginning with dates of review on and after November 1, 2018, the following updates will apply to AIM Level of Care Musculoskeletal Surgery Clinical Appropriateness Guidelines:                                                                                                                        

• Addition of criteria for observation in surgical settings, ambulatory surgical centers, and hospital outpatient departments
• Addition of staff, equipment, and resource capabilities in outpatient surgery
• Modifications to the inpatient admission criteria

Ordering and servicing providers may submit prior authorization requests 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.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

Effective for dates of service on and after November 1, 2018, AIM Specialty Health ® (AIM), a separate company, will apply AIM’s Radiation Oncology Clinical Appropriateness Guidelines to prior authorization requests for the services noted below. These guidelines will replace certain Empire radiation oncology medical policies and clinical guidelines, which are being archived. This update applies to Empire plans with radiation oncology services medically managed by AIM.

• Proton beam radiation therapy

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

Please note, this program does not apply to FEP or National Accounts.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

MyDiversePatients.com features robust educational resources to help providers address health care disparities.  You will find:

• CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

Visit  MyDiversePatients.com today to learn more.

We have several incentive programs this year to encourage Medicare Advantage members to obtain preventive screenings.  Members may be rewarded when they complete their annual routine physical with their PCP.  Eligible members will receive a gift card for competing their screening mammogram, a colorectal cancer screening or their diabetes retinal exam.  Our members may ask that you confirm these screenings.

To help our members receive the DME equipment they need and help ensure no disruption in care, it is important to document that they physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. Additional details on this requirement and other information that will help ensure that your prior authorization request for a wheelchair is processed efficiently will be available at Important Medicare Advantage Updates at empireblue.com/medicareprovider.

Empire accepts electronic medication prior authorization requests for Medicare plans. This feature reduces processing time and helps determine coverage quicker. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

Electronic prior authorization (ePA) offers many benefits:

• More efficient review process 
• Ability to identify if a prior authorization is required 
• Able to see consolidated view of ePA submissions in real time
• Faster turnaround times
• A renewal program that allows for improved continuity of care for members with maintenance medication
• Prior authorizations are preloaded for the provider before the expiration date.

Submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

While ePA helps streamline the prior authorization process, if you must initiate a new PA request by fax or phone, please note that the contact numbers for Medicare Prior Authorization will change Sept. 1, 2018.

If you have other questions, please contact the provider service number on the back of the member ID card.

The Centers for Medicare & Medicaid Services recently issued regulations related to opioid analgesics to help improve patient safety and reduce the misuse of opioid analgesics:  https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

Beginning Jan. 1, 2019, all short- and long-acting opioids will reject at the point of sale if prescribed for more than seven days.  This edit applies to members who do not have an opioid prescription in the previous 60 days.  The edit excludes members with cancer or members in hospice. 

These edits are intended to allow those with intractable pain an opportunity to maintain their pain control while helping reduce the potential for misuse or addiction among those who are experiencing acute pain.  

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

• Medical Policy Update
• Prior authorization requirements for Part B drugs: Azedra and Poteligeo  
• Prior authorizations required for new group-sponsored MA membership 
• Improve Medicare Advantage members’ medication adherence with 90-day prescriptions 
• Prior authorization requirements for cardiovascular services  
• Medicare Advantage reimbursement policy provider bulletin  

72598MUPENMUB 06/18/2018

Recently, Empire BlueCross BlueShield HealthPlus (Empire) partnered with Availity as our designated Electronic Data Interchange (EDI) gateway and E-Solutions Service Desk, and Empire will not renew existing contracts with clearinghouse vendors. As a result, beginning January 1, 2019, Availity will manage all EDI trading partner relationships on behalf of Empire. This new partnership will not interrupt your current services.

Transmitting 837 claims

If you currently transmit 837 claims using a clearinghouse, you should contact your clearinghouse as soon as possible to confirm your EDI submission path for Empire transactions has not changed. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Direct submitters can also use Availity for their 837 transmissions.

Registering with Availity

If you choose to submit directly through Availity but are not yet a registered user, go to https://www.availity.com and select REGISTER. The registration wizard will lead you through the enrollment process. Once complete, you will receive an email with your login credentials and next steps for getting started. If you have any questions or concerns please contact Availity at 1-800-AVAILITY (1‑800-282-4548).

It is our priority to deliver a smooth transition to Availity for our EDI services. If you have questions please contact your Provider Relations representative or Provider Services at 1-800-450-8753.

As you know, Empire BlueCross BlueShield HealthPlus (Empire) offers pregnant women several services and benefits through the New Baby, New LifeSM program. It is our goal to ensure all pregnant members are identified early in their pregnancy so they can take full advantage of the education, support, resources and incentives Empire provides throughout the prenatal and postpartum period.

We’ve partnered with Availity, the vendor supporting the Benefit Look-Up tool you may currently use in your OB office, to send us information about newly identified pregnant women. This new process, including the HEDIS® Maternity Attestation form, helps connect patients with additional benefits as soon as possible. The reporting process includes a few simple steps.

How it works

When an Empire member of childbearing age visits the OB office, the office associate asks if the member is pregnant during the eligibility and benefits inquiry process. If the member is pregnant, the system asks about the due date, and a HEDIS Maternity Attestation form is generated for the OB office to complete. On this electronic form, providers are asked to provide other important information, including the date of the first prenatal care visit, delivery date and postpartum visit date.

This new, user-friendly workflow generates timely information that aids members, providers and Empire in improving birth outcomes with early intervention.

We are working hard to support providers throughout New York in receiving necessary training for this new workflow. If you have specific questions regarding the new Availity maternity attestation process, please feel free to call Provider Services at 1-800-450-8753.

Effective November 1, 2018, Empire BlueCross BlueShield HealthPlus (Empire) will update the claims processing system to ensure accurate payment of newborn claims in accordance with New York normal newborn diagnosis-related group (DRG) requirements and Empire’s inpatient authorization requirements.

All newborn inpatient stays must have sufficient documentation provided to support an admission to an area beyond the newborn nursery, such as a neonatal intensive care unit (NICU) or for the higher level of care associated with the more complex newborn DRG. Documentation to support the higher level admission includes authorization or medical records.

Failure to provide the appropriate documentation will result in the claim being processed based on the normal newborn rate. Please note that current authorization guidelines for normal newborn and higher level of care baby inpatient stays will be applied.

For more information about this update, please go here.

Effective September 1, 2018, prior authorization (PA) requirements will change for injectable drug Cabazitaxel (Jevtana) to be covered by Empire BlueCross BlueShield HealthPlus. 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:

• Cabazitaxel (Jevtana) — injection, 1 mg (J9043)

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. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool (https://www.availity.com). Contracted and noncontracted providers who are unable to access Availity may call us at 1-800-450-8753 for PA requirements.

Effective September 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drugs mepolizumab (Nucala®) and reslizumab (Cinqair®). 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:

• Mepolizumab (Nucala) — injection, 1 mg (J2182)
• Reslizumab (Cinqair) — injection, 1 mg (J2786)

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 through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-450-8753.

Obesity is a serious issue in the United States. The obesity rate is rising. Obesity has significant health consequences, contributing to increased incidence of several diseases, including metabolic syndrome, high blood pressure, diabetes, heart disease, high blood cholesterol, sleep disorders and cancers.

For detail information on obesity HEDIS® measurements and coding, please view the full update at

https://mediproviders.empireblue.com/Documents/NYNY_NYE_ObesityCodingSpotlight.pdf.

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

(Policy 06-111 — effective 11/01/2018)

In applicable circumstances, the appropriate modifier, condition code or value code (identified below) should be used to identify a medically recalled item. This will assist Empire BlueCross BlueShield HealthPlus in identifying medically recalled items and support correct coding guidelines.

Applicable condition codes are 49 and 50. Condition code 49 signifies products replaced within the product lifecycle due to the product not functioning properly, and condition code 50 is used for product replacement for known recall of a product.

When a credit or cost reduction is received by the provider for the replacement device, applicable modifiers are FB and FC. Modifier FB is used when items are provided without cost to the provider, supplier or practitioner, and modifier FC is used when a partial credit is received by the provider, supplier or practitioner for the replacement device.

Note: In circumstances where we have reimbursed the provider for repair or replacement of items or procedures related to items due to a medical recall, we are entitled to recoup or recover fees from the manufacturer and/or distributor as applicable. In circumstances where we have reimbursed the provider the full or partial cost of a replaced device and the provider received a full or partial credit for the device, we are entitled to recoup or recover fees from the provider.

Please refer to CMS and/or your state’s guidelines, and the Medical Recalls reimbursement policy for additional details at www.empireblue.com/nymedicaiddoc.

Empire BlueCross BlueShield HealthPlus needs to report measurements according to the HEDIS® Quality Assurance Reporting Requirements (QARR) for measurement year 2018. Four new measures are specific to New York State, and two of them apply to pharmacotherapy:

• Use of Pharmacotherapy for Alcohol Abuse or Dependence — This measure captures the percentage of members with an alcohol abuse or dependence diagnosis using at least one prescription medication for appropriate pharmacotherapy during the measurement year.
• Initiation of Pharmacotherapy upon New Episode of Opioid Dependence — This measure captures the percentage of members who initiate pharmacotherapy with at least one prescription or visit for opioid treatment medication within 30 days following an index visit and opioid dependence diagnosis.
• Continuity of Care from Inpatient Rehabilitation for Alcohol and Other Drug Abuse or Dependence Treatment to Lower Level of Care — This two-part measure pertains to members 13 and older who receive inpatient treatment for either alcohol or other substance dependence and who have had a follow-up lower-level visit for alcohol or substance dependence within 14 days of the discharge date.
• Potentially Preventable Mental Health Related Readmission Rate 30 Days — This measure addresses the importance of outpatient continuity of care for both behavioral health and physical health concerns. This measure will be calculated by the New York State Office of Quality and Patient Safety.

In addition to those four measures, we continue to track the following measures:

• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) — This measure addresses patients newly diagnosed with a substance use disorder, recommending that they are seen within 14 days of their diagnosis for a follow-up visit. After this visit, it is recommended they are seen for two more visits within 30 days. Another requirement of this measure is that all members receiving mental health treatment are screened during intake for substance abuse. All visits must be documented.
• Follow-Up After Emergency Department Visit for Mental Illness/Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUM/FUA) — These measures require that members with primary mental health or primary substance abuse diagnoses are seen by an outpatient provider within seven days following discharge from an emergency room visit. Commitment to these important measures will address preventive, acute and chronic behavioral health care issues for members.

Thank you for your collaboration on HEDIS QARR measures. Please remember to document your hard work.

Home- and community-based services (HCBS) provide opportunities for Health and Recovery Plan (HARP) beneficiaries to receive services in their own home or community rather than institutions or other isolated settings.

This service can be accessed after the case management agency completes the eligibility assessment. A determination is then made as to whether the member is considered within tier one, tier two or not eligible for HCBS. Respite services do not require an eligibility assessment or a plan of care (POC) to be completed. Respite providers may contact the health plan directly for authorization of services.

Tier 1 -
Short-term crisis respite - no assessment of POC needed
Prevocational
Transitional employment
Intensive supported employment
Ongoing supported employment
Education support services
Peer

Tier 2 -
Psychosocial rehabilitation

Not Eligible - 
Community psychiatric support and treatment
Habilitation supports services
Family support skills training

Level of service determination (LOSD) letters

An LOSD letter request may be written or verbal and, at a minimum, should include the following information:

1. All services the individual is receiving
2. Tier eligibility
3. Person-centered goals
4. Recommended (HCBS) service
5. Housing setting

Submission information

A LOSD request, single POC or finalized POC, can be sent via email or fax:

Email: NYHARP@empireblue.com

Fax: 1-844-528-3686

State Designated Entities

The State has established processes and protocols for managed care organizations to partner with state-designated entities to assist in efforts to ensure HARP members who are not currently enrolled in Health Homes are given the opportunity to access HCBS.

State-designated entities will conduct the NYS Eligibility Assessment for adult behavioral health (BH) HCBS. State-designated entities will use the NYS Eligibility Assessment to determine a HARP member’s eligibility for BH HCBS (tier 1, tier 2, or not eligible for HCBS).

Once determined the member is eligible for, and wishes to access HCBS, a request will be made for an LOSD. The state-designated entity will offer the member a choice of HCBS providers, make referrals to the appropriate HCBS providers, and develop and maintain the HCBS POC.

For more information

To speak with either an HCBS or a state-designated entity representative, please contact:

• Indira Green: 347-346-2984
• Merlann Haigler: 347-920-7939
• Member Services: 1-800-300-8181

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://mediproviders.empireblue.com/ny/pages/quality-assurance.aspx.

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below. To access UM criteria online, go to https://mediproviders.empireblue.com/ny/pages/quality-assurance.aspx.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Calling us at 1-800-450-8753.
• Faxing to 1-800-964-3627.

Have questions about utilization decisions or the UM process?

Call our Clinical team at 1-800-450-8753 Monday through Friday from 8 a.m. to 7 p.m. Eastern time.

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Empire BlueCross BlueShield HealthPlus has adopted a Member’s Rights and Responsibilities Statement, which is located in your Provider Manual.

If you need a physical copy of the statement, call us at 1-800-450-8753.