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 current health crisis illuminates this quite clearly.  It is imperative to offer care that is tailored to the unique needs of patients, and Empire BlueCross BlueShield is committed to supporting our providers in this effort. 

 

MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:

• Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers 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.

 

Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

 

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

 

Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.

 

My Diverse Patients

Stronger Together Health Equity Resources

584-0820-PN-NY

 

Empire BlueCross BlueShield (“Empire”) appreciates the role you play in managing the health of our members.  As the physician of a patient who has coverage compliant with the Affordable Care Act (ACA), you play a vital role in accurately documenting the health of the patient to help ensure compliance with ACA program reporting requirements. When patients visit your practice, we encourage you to document ALL of their health conditions, especially chronic diseases.  Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.

 

Please ensure that all codes captured in your electronic medical record (EMR) system are also included on the claim(s), and are not being truncated by your claims software management system.  For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing four.  If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.

 

Reminder about ICD-10 coding

The ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits.  Additionally, Empire uses ICD-10 codes submitted on claims to monitor health care trends, cost, and disease management. Additionally, the Centers for Medicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a patient’s health.

 

Using specific ICD-10 diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
• Include any secondary diagnosis codes that are actively being managed.
• Include all chronic historical codes, as they must be documented each year pursuant to the ACA.  (Such as an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions.   ICD-10 coding guidelines still apply, so please ensure coding on a telehealth visit claim is to the highest specificity with all diagnosis codes.  Previous Provider News editions provide telehealth reimbursement guidance to follow for claims submission.

 

If you are interested in a coding training session specific to risk adjustable conditions, please contact the Commercial Risk Adjustment Network Education Representative: Alicia.Estrada@anthem.com.

 

567-0820-PN-NY

 

Standard documentation requirements help to ensure consistency of health care for our members. These standards are reviewed annually to ensure they align with our current policies. These standards ensure effective medical record documentation and provide clear and consistent guidelines to ensure that providers maintain records in a current, organized, and effective manner. The medical record criteria that is encouraged for our network of independently contracted providers are outlined below.

1. Every page in the medical record contains the patient name or ID number.
2. Allergies/No Known Drug Allergies (NKDA) and adverse reactions are prominently displayed in a consistent location.
3. All presenting symptom entries are legible, signed and dated, including phone entries. Dictated notes should be initialed to signify review.  Signature sheet for initials are noted.
4. The important diagnoses are summarized or highlighted.
5. A problem list is maintained and updated for significant illnesses and medical conditions.
6. A medication list or reasonable substitute is maintained and updated for chronic and ongoing medications.
7. History and physical exam documentation identifies appropriate subjective and objective information pertinent to the patient’s presenting symptoms, and treatment plan documentation is consistent with findings.
8. Laboratory tests and other studies are ordered, as appropriate, with results noted in the medical record. (The clinical reviewer should see evidence of documentation of appropriate follow-up recommendations and/or non-compliance to care plan).
9. Documentation of Advance Directive/Living Will/Power of Attorney discussion (including copies of any executed documents) in a prominent part of the medical record for adult patients is encouraged.
10. Documentation of continuity and coordination of care between the PCP, specialty physician (including BH specialty) and/or facilities if there is reference to referral or care provided elsewhere. The clinical review will look for a summary of findings or discharge summary in the medical record. Examples include progress notes/report from consultants, discharge summary following inpatient care or outpatient surgery, physical therapy reports, and home health nursing/ provider reports.
11. Age appropriate routine preventive services/risk screening is consistently noted, i.e. childhood immunizations, adult immunizations, mammograms, pap tests, etc., or the refusal by the patient, parent or legal guardian, of such screenings/immunizations in the medical record.

 

582-0820-PN-NY

 

Empire BlueCross BlueShield (“Empire”) and Availity Electronic Data Interchange (EDI) is excited to announce the Prior Authorization/Referrals 278 and Inpatient Admission and Discharge Notification 278N 5010 transactions functionality is coming soon.

 

Prior Authorization and Referral Request (278)

The EDI 278 transaction supports healthcare providers to submit an authorization and referral requests electronically.

 

A prior authorization issued by Empire provides you the go-ahead to perform the necessary service and a referral used to refer a member to a specialty provider. Transmit this transaction in real-time or batch mode. You will receive confirmation numbers to validate receipt of request.

Inpatient Admission and Discharge Notification 278N

Use the Hospital Admission Notification (278N) transaction to exchange admission notification data between an inpatient facility and Empire in a standard format.

Similar to the HIPAA 278 transaction that you may already use to submit authorizations or referrals, the EDI 278N is the simplest, most efficient way to communicate facility admissions. You can also transmit through Availity in either batch or real-time format.

What are the benefits of 278 and 278N transaction?

• Simplify administrative tasks and increase productivity.
• Reduce administrative costs through automation and fewer phone calls, faxes or keying.
• Increase data accuracy by reducing manual errors.

Specifically for 278N, hospitals that have implemented EDI 278N:

• Experience an improvement in notification submissions within 24 hours.
• Can confirm a notification of admission is on file in the form of a service reference number generated upon registration.
• Submit notification of discharge.

How to send a 278 and 278N Transaction

Look for more communications coming soon around how to work with your practice management software vendor or billing/service clearinghouse or view a companion guide to send a 278 or 278N transaction.

 

588-0820-PN-NY

Empire BlueCross BlueShield (“Empire”) and Availity Electronic Data Interchange (EDI) is excited to announce the X12 275 5010 version of electronic attachments transactions for claims functionality is now available for you.

 

The X12 275 5010 version of electronic attachments transactions for claims will:

• Bring value to you by eliminating the need for mailing paper records.
• Electronic acknowledgment provides a transaction audit trail – proof of delivery/receipt.
• Reduces administrative cost associated with manual processing
• Save time waiting for paper correspondents

 

This new functionality includes both solicited and unsolicited attachments.

• Solicited Attachment - Documentation submitted in response to a specific request.
• Unsolicited Attachment - Documentation is known to be needed and submitted at the same time as the claim.

 

How to send a 275 transaction

Your practice management software or billing service/clearinghouse must have the ability to send a 275. We encourage you to have a conversation with them to determine their ability to set up the X12 275 attachment transaction capabilities.

 

Where to find help

The new EDI batch process, X12 275 5010v Companion Guide, assists with specific attachment requirements and enables providers to electronically submit attachments based on your business needs.

• The companion guide can be download at: empireblue.com/edi/
• Availity documentation can be found at: availity.com
• Use the “Availity Welcome Application” below to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.
• EDI Welcome App: https://apps.availity.com/web/welcome/#/  

 

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 8 a.m. - 7 p.m. ET

 

587-0820-PN-NY

 

The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA). The objective of the CLIA program is to ensure quality laboratory testing.

 

A valid CLIA Certificate Identification number is required and must be included on each electronic claim billed for laboratory services, subject to CLIA legislation. You may not receive reimbursement for your electronic claims if the required certification number is missing.

 

How to apply for a CLIA Certificate: 

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/How_to_Apply_for_a_CLIA_Certificate_International_Laboratories

 

This CMS mandate went in to effect on May 1, 2020. Please work with your software vendor or clearinghouse to ensure that the required information is included in your electronic files to avoid EDI claim rejections.

 

For detailed information on the tests subject to CLIA, please refer to the CMS link below:

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/                       

 

586-0820-PN-NY

 

There is no doubt the coronavirus (COVID-19) crisis has taken a toll on all of us. The pandemic has led to immeasurable challenges but we are here to help you ease back into business. We want to remind you, as the Availity migration continues full speed ahead, Empire BlueCross BlueShield (“Empire”) will guide you to make it a smooth transition Just as all good things end, such as summer, the Availity EDI migration also has a target closing date of September 15, 2020.

 

Take Action Today: Availity setup is simple and at no cost for you!

Use this “Welcome” link to get started today: https://apps.availity.com/web/welcome/#/

All EDI transmissions currently sent or received today via the Empire gateway are now available on the Availity EDI Gateway. 

• 837 Institutional and Professional
• 837 Dental
• 835 Electronic Remittance Advice
• 276/277 Claim Status
• 270/271 Eligibility Request
• 275 Medical Attachments
• 278 Prior Authorization/Referrals
• 278N Inpatient Admission and Discharge Notification

 

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

Migrate your direct connection with Empire and become a direct submitter with Availity.

 

Use your existing Clearinghouse or Billing Company for your EDI transmissions.  (Work with them to ensure connectivity to the Availity EDI Gateway).

 

Use Direct Single Claim entry through the Availity Portal.

 

Show your team what you learned this summer!

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

 

Follow these steps to register at www.Availity.com :

1. Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).
2. Select Sessions from the menu under the search catalog field.
3. Scroll Your Calendar to locate your webinar.
4. Select View Course and then Enroll. The ALC will email you instructions to attend.

 

If you and your clearinghouse have already migrated over to Availity, thank you and you are a step ahead! If not, start the process now to make the transition before September 15, 2020.

 

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 8 a.m. - 7 p.m. ET.

 

585-0820-PN-NY

 

Effective November 1, 2020, the AIM Musculoskeletal Program will be expanded to include medical necessity reviews for certain elective surgeries of the small joints for Empire BlueCross BlueShield (“Empire”) members. AIM Specialty Health_® (AIM) will perform the expanded musculoskeletal program and will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (level of care review). The clinical guidelines adopted by Empire and used by AIM to review for medical necessity and level of care are located here: AIM Small Joint Surgery Guideline and AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures.

 

AIM will begin accepting prior authorization requests on October 26, 2020, for dates of service on and after November 1, 2020. To determine if prior authorization is required, please call the prior authorization number located on the back of the member’s ID card. 

 

Members included in the new program

All fully insured and administrative services only (ASO) members currently participating in the AIM Musculoskeletal Program are included. For ASO groups that currently do not participate in the AIM Musculoskeletal Program, the program will be offered to ASOs to add to their members’ benefit package as of November 1, 2020.

 

Pre-service review requirements

For surgeries scheduled to begin on or after November 1, 2020, all providers must contact AIM to obtain prior authorization for the following non-emergency modalities:

 

Small joint replacement (including all associated revision surgeries)

• Total joint replacement of ankle
• Correction of Hallux Valgus
• Hammertoe repair

 

Surgeries performed as part of an inpatient admission are included. 

 

To place a review request:

• Online: Get fast, convenient, online service via the AIM ProviderPortal_SM , available twenty-four hours a day, seven days a week, processing requests in real-time using clinical criteria.  Go to aimspecialtyhealth.com/goweb to register. 
• Phone: Call AIM Specialty Health toll-free at 1-877-430-2288, Monday through Friday 8:30 a.m. – 7:00 p.m. 

 

For more information:

Go to www.aimprovider.com/msk for resources to help your practice get started with the musculoskeletal and pain management program. Our website provides access to helpful information and tools such as order entry checklists, clinical guidelines and FAQs.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

571-0820-PN-NY

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

• Updates to AIM musculoskeletal program clinical appropriateness guidelines
• Submit behavioral health authorizations via our online Interactive Care Reviewer tool
• Medicare Advantage Provider data update
• Updates to AIM musculoskeletal program clinical appropriateness guidelines

To support improvement of health outcomes for our members, cost-sharing requirements (copays, deductibles and coinsurance) are not applied to chronic care management (CCM) and transitional care management (TCM) services for Medicare Advantage plans (with the exception of Dual-Eligible Special Needs Plans [D-SNPs]), effective for dates of service on and after September 1, 2019.

 

CCM, complex CCM and TCM services will be allowed per Medicare coverage guidelines. Members and providers must still meet criteria set by Medicare. These services require advanced consent from the member, which must be documented in the patient’s medical record.

 

The following services are included:

Initiation of CCM or complex CCM:	G0506 — Comprehensive assessment and care planning by the physician or other qualified health care professional for patients requiring chronic care management services
CCM:	99490  — CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline Comprehensive care plan established, implemented, revised or monitored
	99491 — CCM services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline Comprehensive care plan established, implemented, revised or monitored

 

Complex CCM:	99487 — Complex CCM services, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline Establishment or substantial revision of a comprehensive care plan Moderate or high complexity medical decision making 60 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month
	99489  — Complex CCM services, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline Establishment or substantial revision of a comprehensive care plan Moderate or high complexity medical decision making Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month (list separately in addition to code for primary procedure)
TCM:	99495 — Transitional care management services with the following required elements: Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit within 14 calendar days of discharge
	99496 — Transitional care management services with the following required elements: Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge Medical decision making of high complexity during the service period Face-to-face visit within seven calendar days of discharge

 

EBSCRNU-0117-20 June 2020

510548MUPENMUB

 

This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).

 

Empire partners with AIM Specialty Health_®* (AIM), a leading specialty benefits management company that provides services for radiology, cardiology, genetic testing, oncology, musculoskeletal, rehabilitation, sleep management, and additional specialty areas. Partnerships like this require that Empire's provider demographic information (group or practice name, additional providers added to the group/practice, location) is current and accurate to eliminate provider and member abrasion.

 

In the event the provider's demographic information has not been updated in Empire's system, the data will also be missing from the provider data that goes to AIM. Therefore, providers may not be able to locate the requested record in AIM's system. While the provider's information can be manually entered to build a case, the record will appear to be out-of-network, and the case will adjudicate accordingly.

 

Empire provider data updates flow to AIM via the provider data extract, but the data flow does not work in the reverse back to Empire. It is important that providers make the following changes or updates with Empire, not AIM:

• Group or practice name
• TIN
• NPI
• Address (add/remove location(s), corrections)
• Phone numbers
• Fax numbers
• Any additional changes

 

If Providers have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services:

• Medicaid: 1-800-450-8753
• Medicare Advantage: Call the number on the back of members’ ID cards

 

NYE-NU-0227-20 June 2020

510499MUPENMUB

 

On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, use this email.

 

EBSCRNU-0118-20 June 2020

510564MUPENMUB

 

Effective November 1, 2020, AIM Specialty Health_® (AIM)*, a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joint for Medicare Advantage (MA) patients, as further outlined below.

 

AIM will follow the Empire BlueCross BlueShield (Empire) clinical hierarchy for medical necessity determination. For Medicare Advantage products AIM makes clinical appropriateness based on CMS National Coverage Determinations, Local Coverage Determinations, other coverage guidelines, and instructions issued by CMS and legislative benefit changes. Where the existing CMS guidance provides insufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

 

Prior authorization requirements

For services scheduled on or after November 1, 2020, providers must contact AIM to obtain prior authorization for the services detailed below. Providers are strongly encouraged to verify they have received a prior authorization before scheduling and performing services.

 

Detailed prior authorization requirements are available to contracted providers by accessing the Availity Portal* at www.availity.com. Contracted and non-contracted providers may call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed.

 

Small joint replacement (including all associated revision surgeries)

• Total joint replacement of the ankle
• Correction of hallux valgus
• Hammertoe repair

 

The expanded musculoskeletal program will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (Level of Care review). Procedures performed as part of an inpatient admission are included. The clinical guidelines that have been adopted by Empire BlueCross BlueShield to review for medical necessity and level of care are located at:

• AIM Small Joint Surgery Guideline
• AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures

 

How to place a review request

You may place a prior authorization request online via the AIM ProviderPortal_SM. This service is available 24/7 to process requests using Clinical Criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 7 a.m. to 7 p.m. Central time.

 

For more information

For resources to help your practice get started with the musculoskeletal program, go to www.aimprovider.com/msk.

 

This provider website will help you learn more and provide useful information and tools such as order entry checklists, clinical guidelines, and FAQs.

 

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

 

EBSCRNU-0122-20 June 2020

511046MUPENEBS

 

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

 

Medicare Risk Adjustment and Documentation Guidance (general)

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

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

* Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (condition specific)

• When: This training is offered on the third Wednesday of every other month from noon to 1 p.m. ET.
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity, Medicare Risk Adjustment Documentation and Coding Guidance, from
  January 15, 2020, to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

EBSCRNU-0120-20 June 2020

510874MUPENMUB

 

Please continue to check Medicaid Provider Communications & updates at www.empireblue.com/nymedicaiddoc for the latest Medicaid information, including:

• Updates to AIM musculoskeletal program clinical appropriateness guidelines

Effective October 1, 2020, Empire BlueCross BlueShield will transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Specialty Health_®^* Rehabilitative Service Clinical Appropriateness Guidelines as part of the AIM rehabilitation program. Reviewed services will include certain physical therapy, occupational therapy and speech therapy services.  

 

As part of this transition of clinical criteria, the following procedures will be subject to prior authorization as part of the AIM rehabilitation program: 

 

CPT® code	Description
90901	Biofeedback training by any modality (when done for medically necessary indications)
90912	Biofeedback training for bowel or bladder control, initial 15 minutes
90913	Biofeedback training for bowel or bladder control, additional 15 minutes
96001	Three-dimensional, video-taped, computer-based gait analysis during walking
0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
S8940	Therapeutic horseback riding, per session
S8948	Treatment with low level laser (phototherapy) each 15 minutes
S9090	Vertebral axial decompression (lumbar traction), per session
20560	Needle insertion(s) without injection(s), 1 or 2 muscle(s)
20561	Needle insertion(s) without injection(s), 3 or more muscle(s)
97129	One-on-one therapeutic interventions focused on thought processing and strategies to manage activities
97130	Each additional 15 minutes (List separately in addition to code for primary procedure.)
92606	Therapeutic services for use of non-speech-generating device with programming
92609	Therapeutic services for use of speech-generating device with programming
92630	Hearing training and therapy for hearing loss prior to learning to speak

 

The following procedure will be removed from the program:

• S9117: Back school, per visit

 

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

• Access AIM’s ProviderPortal_SM directly at https://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 Portal* at https://www.availity.com.
• Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. Eastern time.

 

If you have 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 and upcoming guidelines at https://aimproviders.com/rehabilitation.

 

NYE-NU-0225-20 June 2020

This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).

 

Empire BlueCross BlueShield (Empire) partners with AIM Specialty Health_®* (AIM), a leading specialty benefits management company that provides services for radiology, cardiology, genetic testing, oncology, musculoskeletal, rehabilitation, sleep management, and additional specialty areas. Partnerships like this require that Empire's provider demographic information (group or practice name, additional providers added to the group/practice, location) is current and accurate to eliminate provider and member abrasion.

 

In the event the provider's demographic information has not been updated in Empire's system, the data will also be missing from the provider data that goes to AIM. Therefore, providers may not be able to locate the requested record in AIM's system. While the provider's information can be manually entered to build a case, the record will appear to be out-of-network, and the case will adjudicate accordingly.

 

Empire provider data updates flow to AIM via the provider data extract, but the data flow does not work in the reverse back to Empire. It is important that providers make the following changes or updates with Empire, not AIM:

• Group or practice name
• TIN
• NPI
• Address (add/remove location(s), corrections)
• Phone numbers
• Fax numbers
• Any additional changes

 

If Providers have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services:

• Medicaid: 1-800-450-8753
• Medicare Advantage: Call the number on the back of members’ ID cards

 

NYE-NU-0227-20 June 2020

510499MUPENMUB

 

On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. Please note, this does not affect the prescription drug benefit. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, use this email

 

NYE-NU-0231-20 June 2020

This HEDIS^® measure looks at the percentage of members ages 18 to 85 years who have had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg).

 

Record your efforts

Document blood pressure and diagnosis of hypertension. Members whose BP is adequately

controlled include:

• Members 18 to 85 years of age who had a diagnosis of HTN and whose BP was adequately controlled (< 140/90 mm Hg) during the measurement year.
• The most recent BP reading during the measurement year on or after the second diagnosis of HTN.
• If no BP is recorded during the measurement year, assume that the member is not controlled.

 

What does not count for this HEDIS measure?

• If blood pressure is taken on the same day as a diagnostic test or procedure or for a change in diet or medication regimen
• If blood pressure is taken on or one day before the day of any test or procedure
• Blood pressure taken during an acute inpatient stay or an emergency department visit

 

Exclusions:

• End stage renal disease
• Nephrectomy or Kidney transplant
• Pregnancy
• Nonacute inpatient stay
• Members aged 66 to 80 with frailty and advanced illness
• Members 81 years old and above with frailty

 

Helpful tips:

• Have your office staff recheck blood pressure for members with initial diagnosis of hypertension and record readings greater than 140 mm Hg systolic and 90 mm Hg diastolic during outpatient office visits. Educate your staff to record the recheck in member’s medical records.
• Refer high-risk members to our hypertension programs and other programs for additional education and support.
• Educate members and their spouses, caregivers or guardians about the elements of a healthy lifestyle such as:
• Heart-healthy eating and a low-salt diet.
• Smoking cessation and avoiding secondhand smoke.
• Adding regular exercise to daily activities.
• Home BP monitoring.
• Ideal BMI.
• The importance of taking all prescribed medications as directed.
• Remember to include the applicable Category II reporting code on the claim form to help reduce the burden of HEDIS medical record review

 

How can we help?

We support you in helping members control high blood pressure by:

• Providing online Clinical Practice Guidelines on our provider
• Reaching out to our hypertensive members through our education and support programs.

 

Other available resources:

• National Heart, Lung, and Blood Institute
• CDC Blood Pressure educational materials

 

NYE-NU-0228-20 June 2020