We’re making it even easier for you to schedule online appointments through the Appointment Scheduler App on Availity.  The Appointment Scheduler App gives you secure access to new appointment requests. You’ll also receive digital access to the member’s ID number, contact information and any special health information.

 

Appointment Scheduler App features include:

• Manage appointment requests
• Configure appointment availability
• Notifications for new visit requests on your Availity dashboard
• Members are automatically notified by text or email when appointments are confirmed

Administrators, administrator assistants and users with the role of “office staff” will have access to the Appointment Scheduler App.

 

To access Appointment Scheduler, log onto Availity.com and select Anthem from Payer Spaces. The Appointment Scheduler App will be in your Applications menu. To learn more about the new App, visit the Custom Learning Center in Availity keyword search Appointment Scheduler.

 

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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.

 

Clinical Guideline Updates

 

New Clinical Guideline Effective 11-01-2021

(The following guideline is new and has been adopted.)

• CG-MED-89 – Home Parenteral Nutrition

 

Corrections to the Medical Policy Update section of the July 2021 Newsletter
In the July 2021 provider newsletter, providers were advised that SURG.00127 Sacroiliac Joint Fusion would be archived effective on September 12, 2021, with minimally invasive sacroiliac joint fusion transitioned to an AIM guideline and open sacroiliac joint fusion converted to a clinical UM guideline (CG-SURG-111 Open Sacroiliac Joint Fusion). We wanted to advise that this medical policy will be archived effective on July 30, 2021.

 

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Effective November 1, 2021, Empire BlueCross BlueShield (“Empire”) will transition the clinical criteria for medical necessity review of Computed Tomography to Detect Coronary Artery Calcification to AIM Imaging of the Heart Clinical Appropriateness Guideline. 

 

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

 

CPT code	Description
75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery calcium
S8092	Electron beam CT (also known as ultrafast CT, cine CT)

 

• Access AIM’s ProviderPortal_SM 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 and upcoming guidelines here.

 

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Beginning with dates of service on or after November 1, 2021, Empire BlueCross BlueShield’s current Telehealth policy will be renamed Virtual Visits. Empire allows reimbursement for professional and facility Virtual Visits when interactive services occur between the member and the provider, when they are not in the same location, unless provider, state, or federal contracts and/or mandates indicate otherwise. Reimbursement is allowed for professional and facility Virtual Visits rendered at the distant site via live audio-visual services and for Remote Patient Monitoring.  In addition, facility Virtual Visits will be allowed for the originating site fee.  The Related Coding section details the modifiers allowed for reimbursement.

 

For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.

 

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Beginning with dates of service on or after November 1, 2021, Empire BlueCross BlueShield ("Empire") will update the Related Coding section to indicate no modifier override for the neurostimulator device when billed with the surgical code for the implantation of the neurostimulator device.

 

The code pairs listed below have been added the below pairs to the Related Coding Section:

• L8680 when reported with 63655
• L8679 when reported with 63650
• L8679 when reported with 63655
• L8687 when reported with 63650
• L8687 when reported with 63655

 

For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.

 

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As a reminder, Empire BlueCross BlueShield (“Empire”) does not allow separate reimbursement for claims that have been identified as a readmission for the same, similar or closely-related diagnoses or condition to the same facility or another facility that (i) operates under the same Facility Agreement, (ii) has the same tax identification number as Facility, or (iii) is under common ownership as Facility, as further described in the existing reimbursement policy found on empireblue.com/provider.

 

If Empire determines that this reimbursement policy has not been followed, Empire may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Empire, and Empire policies.

 

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Effective November 1, 2021, in order to help ensure our member’s security, the Blue Cross and Blue Shield Federal Employee Program (FEP®) will be decommissioning the Utilization Management (UM) email address for processing eReviews, FEPE-Reviews@anthem.com.  . 

 

As an alternative, FEP offers our providers a secure online portal, Interactive Care Reviewer (ICR)

 

About the portal

ICR is Empire BlueCross BlueShield’s (“Empire”) innovative UM portal that allows providers, in addition to phone or fax, to submit prior authorization requests and to provide clinical documentation (including imaging) to support initial and continued stay reviews.   This enables prior authorization requests and clinical information to be transmitted directly to UM staff.

 

Key features of the portal

• A no cost electronic UM solution
• Instant access from any location at any time
• Create a UM preauthorization case and instantly submit it for review
• Attach clinical documents for review – no faxing required
• Check status of any case regardless of the method used to originally submit request
• Complete record of submissions and dispositions – all in one place.
• Bi-directional communication.

 

To submit prior authorization service requests electronically, register for use of ICR prior to November 1, 2021 on the Availity portal.

 

For more information on Anthem ICR, including training resources: https://www.anthem.com/provider/prior-authorization/interactive-care-reviewer/

 

Register for ICR via the Availity portal: https://www.availity.com/provider-portal-registration

 

Need help registering? View this video: How to Access Availity and Register

 

As a reminder, in addition to using ICR on the Availity portal, you can submit authorizations, to FEP UM by phone or fax: 

• FEP UM precertification toll free #: 800-860-2156
• FEP UM precertification fax #:800-732-8318
• FEP UM advance benefit determination fax #: 877-606-3807

 

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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.

 

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Prior authorization updates

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

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-0196	J3490, J9999, J3590	Zynlonta
**ING-CC-0197	J3490, J3590, J9999	Jemperli
*ING-CC-0199	J3490, J3590, C9399	Empaveli

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Quantity limit updates

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

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-0199	J3490. J3590, C9399	Empaveli

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

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Effective with dates of service on and after October 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Empire BlueCross BlueShield (“Empire”) will update its drug lists that support commercial health plans.

 

Updates include changes to drug tiers and the removal of medications from the formulary.

 

Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.

 

To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.

 

View a summary of changes here.  

 

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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 a Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Revised Clinical Criteria effective August 1, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0037 Kanuma (sebelipase alfa)
• ING-CC-0043 Monoclonal Antibodies to Interleukin-5
• ING-CC-0057 Krystexxa (pegloticase)
• ING-CC-0066 Monoclonal Antibodies to Interleukin-6
• ING-CC-0068 Growth Hormone
• ING-CC-0069 Egrifta (tesamorelin)
• ING-CC-0111 Nplate (romiplostim)
• ING-CC-0137 Cablivi (caplacizumab-yhdp)
• ING-CC-0153 Adakveo (crizanlizumab)
• ING-CC-0162 Tepezza (teprotumumab-trbw)

 

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Empire BlueCross BlueShield (“Empire”) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

 

Effective with dates of service on or after August 1, 2021, providers treating members covered by Empire Commercial plans may be asked to consider voluntarily using adjusted body weight (AdjBW) dosing compared to actual body weight (ABW) dosing for immune globulin medications. The dose change using AdjBW will only be made if the member’s actual body weight is more than 20% of the ideal body weight (IBW).

 

Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization. 

 

Reviews for the immune globulin medications will continue to be administered by IngenioRx_® as these will specifically target specialty non-oncology indications.

 

As part of the prior authorization process, providers may be asked the following questions:

• Whether the suggested use of AdjBW and change in dose is clinically acceptable
• Clinical reasoning if the dose change (using AdjBW) is not appropriate

 

Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com.

 

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.

 

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Empire BlueCross BlueShield (“Empire”) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

 

Effective with dates of service on or after August 1, 2021, providers treating members covered by Empire Commercial plans may be asked to consider voluntarily reducing the requested dose to avoid vial wastage for select non-oncology specialty medications The dose reduction suggestion will only be made if the originally requested dose is within 10% of the nearest whole vial.

 

Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization. 

 

Reviews for these specialty drugs will continue to be administered by IngenioRx_®.

 

As part of the prior authorization process, providers may be asked the following questions:

• Whether the suggested dose reduction is clinically acceptable
• Clinical reasoning if the dose reduction is not appropriate

 

Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com.

 

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.

 

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Providers treating members covered by Empire BlueCross BlueShield ("Empire") plans will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications (see list below). Reviews for these oncology drugs will continue to be administered by AIM Specialty Health_® (AIM).

 

As part of the online prior authorization process, providers will be asked about the dosage of the medication being requested in pop-up questions:

• Whether or not the recommended dose reduction is acceptable
• 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 prior authorization requests made outside of the online AIM Provider Portal (i.e. via phone or fax) the same questions will be asked by the registered nurse or medical director 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 percent of the nearest whole vial. This threshold is based on the current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) it is appropriate to consider dose rounding within 10 percent. Click here to view the HOPA recommendations.

 

The voluntary dose reduction program only applies to the specific oncology drugs listed below. Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com.

 

Drug Name	HCPCS Code	Drug Name	HCPCS Code
Abraxane (paclitaxel protein-bound)	J9264	Kadcyla (ado-trastuzumab emtansine)	J9354
Actimmune (interferon gamma-1B)	J9216	Kanjinti (trastuzumab-anns)	Q5117
Adcetris (brentuximab vedotin)	J9042	Keytruda (pembrolizumab)	J9271
Alimta (pemetrexed)	J9305	Kyprolis (carfilzomib)	J9047
Asparlas (calaspargase pegol-mknl)	J9118	Lumoxiti (moxetumomab pasudotox-tdfk)	J9313
Avastin (bevacizumab)	J9035	Mvasi (bevacizumab-awwb)	Q5107
Bendeka (bendamustine)	J9034	Mylotarg (gemtuzumab ozogamicin)	J9203
Besponsa (inotuzumab ozogamicin)	J9229	Neupogen (filgrastim)	J1442
Blincyto (blinatumomab)	J9039	Ogivri (trastuzumab-dkst)	Q5114
Cyramza (ramucirumab)	J9308	Oncaspar (pegaspargase)	J9266
Darzalex (daratumumab)	J9145	Ontruzant (trastuzumab-dttb)	Q5112
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	Riabni (rituximab-arrx)	Q5123
Erbitux (cetuximab)	J9055	Rituxan (rituximab)	J9312
Erwinase (asparginase)	J9019	Ruxience (rituximab-pvvr)	Q5119
Ethyol (amifostine)	J0207	Sarclisa (isatuximab-irfc)	J9227
Granix (tbo-filgrastim)	J1447	Sylvant (siltuximab)	J2860
Halaven (eribulin mesylate)	J9179	Trazimera (trastuzumab-qyyp)	Q5116
Herceptin (trastuzumab)	J9355	Treanda (bendamustine)	J9033
Herzuma (trastuzumab-pkrb)	Q5113	Truxima (rituximab-abbs)	Q5115
Imfinzi (durvalumab)	J9173	Vectibix (panitumumab)	J9303
Istodax (romidepsin)	J9315	Yervoy (ipilimumab)	J9228
Ixempra (ixabepilone)	J9207	Zaltrap (ziv-aflibercept)	J9400
Jevtana (cabazitaxel)	J9043	Zirabev (bevacizumab-bvzr)	Q5118

 

Note: In some plans “dose reduction to nearest whole vial” or another term “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” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “dose reduction (to nearest whole vial).”

 

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.

 

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