 Provider News New YorkAugust 2022 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
In the July edition of Provider News, we announced that the updated Physician Office Lab (POL) list was effective August 1, 2022. That date was incorrect, the POL list is effective October 1, 2022.
As a reminder, the Empire BlueCross BlueShield (Empire) POL list can be found online at https://empireblue.com/provider > Provider Forms & Guides > Physician Office Lab (POL) List.
Empire members must be referred to a participating laboratory for any lab services not included on the POL list. Claims submitted to Empire for physician office laboratory services not on the POL list will be denied and members cannot be balance billed.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Submitting your updates promptly helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Using this form, you can update:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging that we received your request. See the Provider Maintenance Form for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield appreciates the feedback you shared about the Availity* Essentials multi-payer authorization application. The insight you provided about your user experience has enabled enhancements that we hope will further improve your experience:
- Easier to track your authorization requests: Case numbers are being returned following your authorization submission, making it easier to track your authorization requests.
- Expanded procedure code options: You can now submit your procedure codes by visits and hours, in addition to days and units.
- Error code improvements: Recognizing that error codes can be difficult to understand, we have rewritten them to be more clear, concise, and actionable.
- Enhancements to the admissions dropdown menu: For outpatient submissions, an enhancement to the level of service improves turnaround time for case decision. For inpatient and outpatient submissions, urgent requests receive a confirmation message.
- Update to Add Attachment feature: We have added a reminder notification that enables you to double check that the attachments are connected to the correct member for the correct
Become an Availity Essentials user today
If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for our providers to register or to use any of the digital applications. Start by logging onto Availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Digital claims attachments expedite claims processing and payment. That’s why we have been hard at work making the digital attachment process easier, more intuitive and streamlined. Now you can add attachments directly to your claim by using the new Send Attachments feature from the Claims Status application on Availity.com.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time because there is no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and personal health information.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the Attachment Control Number, there are three options for submitting attachments:
- Through the Attachments Dashboard Inbox: From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox
- Through the 275 attachment: Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment
- Through the Availity.com application: From Availity.com, select the Claims & Payments tab to run a Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
If you submitted your claim through the Availity Essential Claims application:
- Simply submit your attachment with your claim
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments: From Availity.com, select the Claims & Payments tab and access Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
Learn more about the Send Attachment feature
In collaboration with Availity Essentials, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status workflow. Sign up for a live webinar today:
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Now open for learning!
Access to training for Availity Essentials can be helpful when trying to master applications like claims attachments, authorizations and eligibility and benefits. The Provider Learning Hub on Empireblue.com is not only a new way to access training, it also offers a new learning experience.
Short, easy to follow training videos with supporting resources are available on the Provider Learning Hub – no username and password required. Access it at your convenience and share your learnings with others on your teams. Handy filtering options enable you to quickly find what you are looking for including an option to save trainings to a Favorites folder for easy access later. You will register for the Provider Learning Hub once. On future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today
Access the Provider Learning Hub using this link or from Empireblue.com under Important Announcements on the home page.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Reductions in missed appointments are significant
Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,1” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.
Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.
“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.
Telehealth and telephone visits with members after a behavioral health inpatient stay meet HEDIS® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution2.
The FUH HEDIS measure evaluates:
- Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.
Two areas of importance for this HEDIS measure are:
- The percentage of behavioral health inpatient discharges for which the member received follow-up within seven days after discharge
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.
These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the National Committee for Quality Assurance (NCQA) website.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
These updates list the new and/or revised Empire BlueCross BlueShield (Empire) Medical Policies and Clinical Guidelines. The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline 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 https://www.empireblue.com.
Note: These updates may not apply to all ASO Accounts as some accounts may have nonstandard benefits that apply.
To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program [FEP®]), please visit www.fepblue.org > Policies & Guidelines.
Medical Policy updates
Archived medical policy effective May 19, 2022
The following policy has been archived:
- SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent
Archived medical policy effective June 29, 2022
The following policy has been archived and its content has been transitioned to an existing Clinical UM Guideline:
- MED.00121 Implantable Interstitial Glucose Sensors [Note: Content transitioned to
CG-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps.
Revised medical policies effective June 29, 2022
The following policies were updated with new CPT®/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:
- GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- GENE.00056 Gene Expression Profiling for Bladder Cancer
- LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
Revised medical policies effective June 29, 2022
The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
- MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
Archived medical policies effective July 6, 2022
The following policies have been archived:
- DME.00024 Transtympanic Micropressure
- SURG.00137 Focused Microwave Thermotherapy for Breast Cancer
Archived medical policy effective July 6, 2022
The following policy has been archived and its content has been transitioned to a new Clinical UM Guideline:
- MED.00127 Chelation Therapy [Note: Content transitioned to new clinical UM guideline CG-MED-90 Chelation Therapy.]
Revised medical policies effective July 6, 2022
The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- ADMIN.00002 Preventive Health Guidelines
- ADMIN.00004 Medical Necessity Criteria
- ADMIN.00005 Investigational Criteria
- ADMIN.00007 Immunizations
- ANC.00006 Biomagnetic Therapy
- ANC.00007 Cosmetic and Reconstructive Services: Skin Related
- ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
- DME.00012 Intrapulmonary Percussive Ventilation Devices
- DME.00030 Altered Auditory Feedback Devices for Fluency Disorders
- DME.00037 Cooling Devices and Combined Cooling/Heating Devices
- DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
- DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
- GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00041 Genetic Testing to Confirm the Identity of Laboratory Specimens
- GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
- GENE.00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis
- LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders
- LAB.00029 Rupture of Membranes Testing in Pregnancy
- LAB.00031 Advanced Lipoprotein Testing
- LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
- LAB.00038 Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
- LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline
- MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
- MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
- MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
- MED.00098 Hyperoxemic Reperfusion Therapy
- MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00133 Ingestion Event Monitors
- MED.00137 Eye Movement Analysis Using Non-Spatial Calibration for the Diagnosis of Concussion
- OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis
- OR-PR.00005 Upper Extremity Myoelectric Orthoses
- OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices
- RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
- RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
- SURG.00005 Partial Left Ventriculectomy
- SURG.00007 Vagus Nerve Stimulation
- SURG.00037 Treatment of Varicose Veins (Lower Extremities)
- SURG.00045 Extracorporeal Shock Wave Therapy
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- SURG.00071 Percutaneous and Endoscopic Spinal Surgery
- SURG.00076 Nerve Graft after Prostatectomy
- SURG.00084 Implantable Middle Ear Hearing Aids
- SURG.00095 Viscocanalostomy and Canaloplasty
- SURG.00105 Bicompartmental Knee Arthroplasty
- SURG.00111 Axial Lumbar Interbody Fusion
- SURG.00116 High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
- SURG.00118 Bronchial Thermoplasty
- SURG.00120 Internal Rib Fixation Systems
- SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
- SURG.00126 Irreversible Electroporation
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00134 Interspinous Process Fixation Devices
- SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization
- SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
- SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
- SURG.00147 Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
- SURG.00155 Cryoneurolysis
- THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
- TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Revised medical policy effective July 9, 2022
The following policy was revised to expand medical necessity indications or criteria:
- SURG.00097 Scoliosis Surgery
Archived medical policy effective September 12, 2022
The following policy has been archived and has been replaced by AIM guidelines:
- DME.00039 Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea)
New medical policies effective November 1, 2022
The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- DME.00047 Rehabilitative Devices with Remote Monitoring
- DME.00048 Virtual Reality-Assisted Therapy Systems
- GENE.00059 Hybrid Personalized Molecular Residual Disease Testing for Cancer
- MED.00139 Electrical Impedance Scanning for Cancer Detection
- TRANS.00039 Portable Normothermic Organ Perfusion System
Revised medical policy effective November 1, 2022
The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- GENE.00023 Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma
New medical policies effective November 5, 2022
The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- DME.00046 Intermittent Abdominal Pressure Ventilation Devices
- LAB.00048 Pain Management Biomarker Analysis
Revised medical policy effective November 12, 2022
The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests
Clinical Guideline updates
Revised clinical guideline effective June 29, 2022
The following adopted guideline was updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:
- CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management
Revised clinical guideline effective July 6, 2022
The following adopted guideline was revised to expand medical necessity indications or criteria:
- CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
Revised clinical guidelines effective July 6, 2022
The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- CG-DME-45 Ultrasound Bone Growth Stimulation
- CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
- CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
- CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
- CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
- CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
- CG-MED-89 Home Parenteral Nutrition
- CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
- CG-SURG-27 Gender Affirming Surgery
- CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
- CG-SURG-50 Assistant Surgeons
- CG-SURG-71 Reduction Mammaplasty
- CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
- CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
- CG-SURG-85 Hip Resurfacing
- CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus
- CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
Revised clinical guideline effective November 12, 2022
The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary:
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Visit the Drug Lists page 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.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The commercial and Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
Federal Employee Program Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
The Empire BlueCross BlueShield (Empire) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s Medical Specialty Drug Review team. Oncology drugs will be managed by AIM Specialty Health®* (AIM), a separate company.
The following Clinical Criteria documents were endorsed at the May 20, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, please go here.
Revised Clinical Criteria effective May 20, 2022
The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0065 — Agents for hemophilia A and Von Willebrand Disease
- ING-CC-0148 — Agents for hemophilia B
New Clinical Criteria effective June 2, 2022
The following Clinical Criteria is new:
- ING-CC-0216 — Opdualag™ (nivolumab and relatlimab-rmbw)
Revised Clinical Criteria effective June 2, 2022
The following Clinical Criteria was revised to expand medical necessity indications or criteria:
- ING-CC-0194 — Cabenuva® (cabotegravir extended-release; rilpivirine extended-release) injection
Revised Clinical Criteria effective June 20, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0002 — Colony stimulating factor agents
- ING-CC-0065 — Agents for hemophilia A and Von Willebrand Disease
- ING-CC-0092 — Adcetris® (brentuximab vedotin)
- ING-CC-0106 — Erbitux® (cetuximab)
- ING-CC-0107 — Bevacizumab for non-ophthalmologic indications
- ING-CC-0116 — Bendamustine agents
- ING-CC-0124 — Keytruda® (pembrolizumab)
- ING-CC-0143 — Polivy® (polatuzumab vedotin-piiq)
- ING-CC-0145 — Libtayo® (cemiplimab-rwlc)
- ING-CC-0151 — Yescarta® (axicabtagene ciloleucel)
Revised Clinical Criteria effective June 20, 2022
The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0045 — Increlex® (mecasermin)
- ING-CC-0057 — Krystexxa® (pegloticase)
- ING-CC-0069 — Egrifta® (tesamorelin)
- ING-CC-0098 — Doxorubicin liposome (Doxil®, Lipodox™)
- ING-CC-0105 — Vectibix® (panitumumab)
- ING-CC-0111 — Nplate® (romiplostim)
- ING-CC-0114 — Jevtana® (cabazitaxel)
- ING-CC-0127 — Darzalex® (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- ING-CC-0128 — Tecentriq® (atezolizumab)
- ING-CC-0134 — Provenge® (sipuleucel-T)
- ING-CC-0137 — Cablivi (caplacizumab-yhdp)
- ING-CC-0142 — Somatuline® Depot (lanreotide)
- ING-CC-0160 — Vyepti® (eptinezumab)
- ING-CC-0161 — Sarclisa® (isatuximab-irfc)
- ING-CC-0162 — Tepezza® (teprotumumab-trbw)
- ING-CC-0165 — Trodelvy® (sacituzumab govitecan)
- ING-CC-0166 — Trastuzumab agents
- ING-CC-0169 — Phesgo™ (pertuzumab/trastuzumab/hyaluronidase-zzxf)
- ING-CC-0178 — Synribo® (omacetaxine mepesuccinate)
- ING-CC-0188 — Imcivree™ (setmelanotide)
- ING-CC-0192 — Cosela™ (trilaciclib)
- ING-CC-0199 — Empaveli® (pegcetacoplan)
Revised Clinical Criteria effective July 1, 2022
The following Clinical Criteria were updated with new procedure and/or diagnosis codes:
- ING-CC-0003 — Immunoglobulins
- ING-CC-0203 — Ryplazim® (plasminogen, human-tvmh)
- ING-CC-0205 — Fyarro™ (sirolimus albumin bound)
- ING-CC-0207 — Vyvgart™ (efgartigimod alfa-fcab)
- ING-CC-0209 — Leqvio® (inclisiran)
- ING-CC-0210 — Enjaymo™ (sutimlimab-jome)
- ING-CC-0211 — Kimmtrak® (tebentafusp-tebn)
- ING-CC-0212 — Tezspire™ (tezepelumab-ekko)
- ING-CC-0214 — Carvykti™ (ciltacabtagene autoleucel)
Revised Clinical Criteria effective August 1, 2022
The following Clinical Criteria was updated with new procedure and/or diagnosis codes:
- ING-CC-0072 — Vascular endothelial growth factor (VEGF) inhibitors
New Clinical Criteria effective November 1, 2022
The following Clinical Criteria is new:
- ING-CC-0215 — Ketamine injection (Ketalar®)
Revised Clinical Criteria effective November 1, 2022
The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:
- ING-CC-0002 — Colony stimulating factor agents
- ING-CC-0032 — Botulinum toxin
- ING-CC-0068 — Growth hormone
- ING-CC-0087 — Gamifant® (emapalumab-lzsg)
- ING-CC-0092 — Adcetris (brentuximab vedotin)
- ING-CC-0107 — Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0118 — Radioimmunotherapy and somatostatin receptor targeted radiotherapy (Azedra®, Lutathera®, Pluvicto™, Zevalin®)
- ING-CC-0119 — Yervoy® (ipilimumab)
- ING-CC-0124 — Keytruda (pembrolizumab)
- ING-CC-0145 — Libtayo (cemiplimab-rwlc)
- ING-CC-0153 — Adakveo® (crizanlizumab)
- ING-CC-0175 — Proleukin® (aldesleukin)
- ING-CC-0201 — Rybrevant® (amivantamab-ymjw)
The following Clinical Criteria document was endorsed at the June 23, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, please go here.
Revised Clinical Criteria effective November 1, 2022
The following Clinical Criteria was revised and might result in services that were previously covered but may now be found to be not medically necessary:
- ING-CC-0072 — Vascular Endothelial Growth Factor (VEGF) Inhibitors
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire BlueCross BlueShield’s (“Empire”) medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
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.
Prior authorization updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
| Clinical Criteria |
Drug |
HCPCS or CPT Code(s) |
| ING-CC-0072 |
Alymsys (bevacizumab-maly) |
C9399, J3490, J3590 |
| ING-CC-0107* |
Alymsys (bevacizumab-maly) |
C9399, J3490, J3590, J9999 |
| ING-CC-0216* |
Opdualag (nivolumab and relatlimab-rmbw) |
C9399, J3490, J3590, J9999 |
| ING-CC-0118* |
Pluvicto (lutetium lu 177 vipivotide tetraxetan) |
A9699 |
| ING-CC-0002* |
Releuko (filgrastim-ayow) |
C9096 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0107*
|
Non-preferred
|
Alymsys
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0002*
|
Non-preferred
|
Releuko
|
C9096
|
Courtesy Notice
Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.
Quantity limit updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
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Alymsys (bevacizumab-maly)
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C9399, J3490, J3590
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after September 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions and exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare Part B drugs
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C9399, J3490, J3590, J9999
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Kimmtrak (tebentafusp-tebn)
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C9399, J3490, J3590, J9999
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Enjaymo (sutimlimab-jome)
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C9399, J3590
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Tezspire (tezepelumab-ekko)
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J3490, J3590
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Vabysmo (faricimab-svoa)
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For services beginning on November 1, 2022, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) will be reviewed by myNEXUS * services for Medicare Advantage individual, group retiree solutions (GRS), and dual-eligible plan members. Through this program, myNEXUS clinicians will collaborate with members, caregivers, and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate, least restrictive environment.
How to submit or check a prior authorization request:
For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests through the NexLync website on Sunday, October 30, 2022, and by telephone or fax on Monday, October 31, 2022, for members whose anticipated discharge date is November 1, 2022, or after. Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to November 1, 2022, should be directed to Empire BlueCross BlueShield (Empire).
Providers are encouraged to request authorization using NexLync. Visit https://portal.myNEXUScare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at 833-311-2986.
Please note: myNEXUS will not review authorization requests for durable medical equipment (DME), ambulance, and other related services that do not fall under Medicare-covered home healthcare services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under essential/everyday extras.
To learn more about myNEXUS and upcoming training webinars, visit www.myNEXUScare.com/Anthem or email Provider_Network@myNEXUScare.com.
What if I need assistance?
If you have additional questions, please call the myNEXUS Provider Call Center at 844-411-9622. If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website (https://www.empireblue.com/medicareprovider) for up-to-date contact information or call Provider Services via the number on the back of members’ ID cards.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective November 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical code listed below will require PA by Empire BlueCross BlueShield HealthPlus. Federal and state law, as well as state contract language, and CMS 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:
- L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device
To request a PA, you may use one of the following methods:
- Availity:* Once logged in to Availity at https://www.availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
- Fax: 800-964-3627
- Phone: 800-450-8753
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providerpublic.empireblue.com. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 800-450-8753 for assistance with PA requirements.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The total economic cost of alcohol use disorder (AUD) was estimated to be $249 billion as of 2019, according to the CDC 1 with $27 billion coming from healthcare costs. 2 The CDC projected the total AUD economic impact on society to be $807 per person, per year. 3
AUD and healthcare spending
Alcohol contributes to the highest amount of health plan spending related to substance use. 36% of Medicaid substance use claims were related to alcohol in 2020, accounting for over $129 million — an increase of 16% from 2019. Additionally, people with AUD are more likely to be high-cost claimants. In government and commercially insured patients across the country, the top 5% of high-cost claimants have either an existing AUD or health conditions resulting from alcohol use.4
AUD and the workforce
AUD also has a significant economic effect on the workforce by way of tardiness, absenteeism, employee turnover and conflict. It causes a reduction in potential employees, customer base and the taxpayer base.5
AUD and mortality
Alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015, according to the CDC. This was more than all other illicit substances combined including opioids, heroin, fentanyl and methamphetamines. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost (YPLL) for the same period. YPLL is the estimation of the average time a person would have lived had they not died prematurely.6
Below is the YPLL related directly or indirectly to AUD.
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Cause
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YPLL
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Total YPLL
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> 2.7 million
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100% alcohol attributed disease
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684,750
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Suicide
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334,058
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Motor vehicle crashes
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323,610
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Liver disease
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202,391
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Heart disease
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118,021
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Cancer
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88,729
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What if I need assistance?
If you need assistance connecting your patients to AUD or substance use treatment, please visit the Contact Us section at the bottom of our provider website (https://providerpublic.empireblue.com) for up-to-date contact information.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. COVID-19 impact on opioid and substance use disorders
As a result of the COVID-19 pandemic, there has been a 20% increase in substance use nationwide, and nearly 100,000 opioid overdose related deaths between 2020 and 2021.1 Black Americans have been disproportionately affected by this increase in overdoses.2 Increasing screening, brief intervention, and referral to treatment (SBIRT) may help provide an opportunity to engage those with emerging and existing substance use disorders through proactive identification and connection to professional services when indicated.
SBIRT resources for providers
A provider toolkit for SBIRT is available on the Empire BlueCross BlueShield HealthPlus provider portal. This toolkit includes SBIRT collateral materials for your use, which outline recommended screening tools, a guided SBIRT process, and resources to help identify appropriate referrals.
More about the SBIRT approach
SBIRT is a “comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with substance use disorders (SUD), as well as those who are at risk of developing these disorders,” according to the Substance Abuse and Mental Health Service Administration (SAMHSA). The goal of SBIRT is to reduce the potential consequences of SUDs.3
SBIRT encounters include a brief screening and intervention that identifies:
- One or more behaviors related to risky alcohol or drug use
- Right type and amount of treatment
The screening is a brief set of questions that identify the patient’s risk of SUD-related problems. The brief intervention is a short (15 to 30 minutes) counseling session to raise awareness of the risks. By leveraging motivation enhancement techniques, this seeks to work with the patient where they are at and with what they are ready and willing to do to address identified substance misuse. Referral to treatment helps the patient access specialized treatment when indicated.
The purpose of the encounter is to facilitate change with the patient’s immediate behavior or thoughts about a risky behavior. In addition, SBIRT results help those with higher levels of need to obtain long-term care, including referrals to specialty providers. This evidence-based program (EBP) has been shown to result in a $2 to 4 healthcare savings for every $1 spent.4
Healthcare providers who encounter an at-risk member have an opportunity for early intervention and referral to appropriate treatment. The core goal is to reduce and prevent problematic use, abuse, and dependence on alcohol, opioids, and other substances. SBIRT has been proven effective regardless of age, gender, race, and culture in children, adolescents, and adults.
Encounters with patients in need of SBIRT may occur in public health, non-substance use treatment settings including primary care centers, hospital emergency rooms, trauma centers, and community health settings. Primary care providers (MD/DOs, PAs, ARNPs), behavioral health providers (therapists, counselors, psychiatrists, clinical social workers), and nurses may provide SBIRT.
Recommended screening tools include:
- Alcohol use disorder identification test (AUDIT)5 for adults with alcohol risk
- Drug abuse screening test (DAST-10)6 for adults with drug risk
- Car, relax, alone, forget, family or friends, trouble (CRAFFT)7 for children and adolescents
- Tolerance, worried, eye opener, amnesia, k/cut down (TWEAK)8 for pregnant people
Below is the SBIRT process flow.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. According to the Centers for Disease Control (CDC), one of the largest growing populations for chlamydia are teens and young adults. Chlamydia infection is often asymptomatic, and screening for asymptomatic infection is a cost-effective strategy to reduce transmission and prevent pelvic inflammatory disease among females.
Talking to a teenager about sexual health issues like chlamydia can be difficult. But, left untreated, an affected individual may develop conditions such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. To help get the conversation started, visit the National Chlamydia Coalition website at http://chlamydiacoalition.org for a free Chlamydia How-To Implementation Guide for Healthcare Providers.
Facts about chlamydia:
- The United States Preventive Services Task Force (USPSTF) recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at risk for infection.
- Chlamydia is the most commonly reported sexually transmitted disease (STD) with over 1.8 million cases reported in 2019.
- Young women account for 43% of reported cases and face the most severe consequences of an undiagnosed infection.
- It is estimated that undiagnosed STDs cause infertility in more the 20,000 women each year.
Chlamydia Screening in Women (CHL) HEDIS® Measure
This HEDIS measure looks at the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year, including teens and women who:
- Made comments or talked to you about sexual relations.
- Had a pregnancy test.
- Were prescribed birth control (even if used for acne treatment).
- Received gynecological services.
- Have a history of sexually transmitted diseases.
- Have a history of sexual assault or abuse.
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Description
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CPT® codes
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Chlamydia tests
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87110, 87270, 87320, 87490, 87492, 87810
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Pregnancy test exclusion
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81025, 84702, 84703
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS ® measures for measurement year 2022. Below is a summary of some of the key changes.
Diabetes measures
NCQA has separated the Comprehensive Diabetes Care indicators into stand-alone measures:
- Hemoglobin A1c Control for Patients with Diabetes (Two rates reported: HbA1c Control (< 8%) and Poor Control HbA1c) (> 9%) (HBD)
- Eye Exam for Patients with Diabetes (EED)
- Blood Pressure Control for Patients with Diabetes (BPD)
The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move toward more outcome-based measures.
Race/ethnicity stratification
An important step to address healthcare disparities is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:
- Colorectal Cancer Screening (COL)
- Controlling High Blood Pressure (CBP)
- Hemoglobin A1c Control for Patients with Diabetes (HBD)
- Prenatal and Postpartum Care (PPC)
- Child and Adolescent Well Care Visits (WCV)
NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help identify and reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to advancing health equity in data and quality measurements.
Measure changes
Colorectal Cancer Screening (COL): Measures the percentage of members 45 to 75 years of age who had appropriate screening for ectal cancer. The Medicaid product was added to the administrative data collection method for this measure and the age range was changed to 45 to 75 years of age. Any of the following meet criteria:
- Fecal occult blood test during the measurement year
- Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year
- Colonoscopy during the measurement year or the nine years prior to the measurement year
- CT colonography during the measurement year or the four years prior to the measurement year
- Stool DNA (sDNA) with FIT test during the measurement year or the two years prior to the measurement year
This measure can also be reported as an Electronic Clinical Data Reporting System measure: Colorectal Cancer Screening (COL-E).
Antibiotic Utilization for Respiratory Conditions (AXR): A newly added metric which measures the percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event. This measure was added because antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse.
Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the broader Antibiotic Utilization measure has been retired.
Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line of business, and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.
For a complete summary of 2022 HEDIS changes, visit: https://www.ncqa.org/hedis/measures/.
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