 Provider News New YorkAugust 2023 Provider Newsletter Contents
NYBCBS-CDCRCM-030306-23 Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Availity, LLC is an independent company providing administrative support services on behalf of the health plan Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As the physician of our members who have Affordable Care Act (ACA) health plans, you play a vital role in the success of this initiative and our compliance with ACA requirements. When members visit your practice or office, we encourage you to document all of the members’ health conditions, especially chronic diseases. As a result, there is ongoing documentation to indicate that these conditions are being assessed and managed. Ensuring proper coding on the claim is to the greatest level of specificity can help reduce the number of medical chart requests in the future. Ensure all codes captured in your electronic medical record (EMR) system are included on the claim and not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes. However, a 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 captured. Best practices and documenting guidelines: Use clear terminology.Include a brief statement that updates the status of each diagnosis. For example, use words such as continue, increase, add, name of medication treating the condition, refer to, return to center, follow up, and so on. This informs the coder the condition is current. Include orders for each condition if applicable. For every medication refilled, document a diagnosis and address it in the progress note. Chronic conditions should be evaluated at least once per year. Use the words history of to mean the condition no longer exists. For example: Document the patient has diabetes and hypertension rather than the patient has a history of diabetes and hypertension. Please see forms and guides for a more comprehensive Commercial Risk Adjustment coding brochure.Contact our Commercial Risk Adjustment Network Education representative if you have any questions: For providers in | Commercial Risk Adjustment Network Education representative | California, Colorado, and Nevada | Martha.Bendot@anthem.com | Indiana, Missouri, Wisconsin, Ohio, and Kentucky | Mary.Swanson@anthem.com | New York, Maine, New Hampshire, Connecticut, Georgia, and Virginia | Alicia.Estrada-Hoare@anthem.com |
Thank you for your continued efforts with our Commercial Risk Adjustment Program. NYBCBS-CM-029139-23-CPN28564 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form ( CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners: Claim format and elements | CLIA number location options | Referring provider name and NPI number location options | Servicing laboratory physical location | CMS-1500 (formerly HCFA-1500) | Must be represented in field 23 | Submit the referring provider name and NPI number in fields 17 and 17b, respectively. | Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the servicing address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23. | HIPAA 5010 837 Professional | Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01 | Submit the referring provider name and NPI number in the 2310A loop, NM1 segment. | Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02. |
To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. If you have questions, please contact your Provider Relationship Management representative. NYBCBS-CD-029252-23-CPN29147 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners: Claim format and elements | CLIA number location options | Referring provider name and NPI number location options | Servicing laboratory physical location | CMS-1500 (formerly HCFA-1500) | Must be represented in field 23 | Submit the referring provider name and NPI number in fields 17 and 17b, respectively. | Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the servicing address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23. | HIPAA 5010 837 Professional | Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01 | Submit the referring provider name and NPI number in the 2310A loop, NM1 segment. | Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02. |
To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and/or applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. If you have questions, please contact your Provider Relationship Management representative. Medicare services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC., or Anthem Blue Cross and Blue Shield Retiree Solutions, trade name of Anthem Insurance Companies, Inc.
Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NYBCBS-CRCM-029656-23-CPN29126, NYBC-CRCM-029655-23, NYBCBS-CRCM-066937-24 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. To support the health of our members, Empire BlueCross BlueShield (Empire) is sending urinary tract infection (UTI) tool kits to select members who were seen in the ER for a UTI. This kit contains: - A water bottle to help your patient stay hydrated.
- UTI test strips with instructions on use if having symptoms. These test strips are available over the counter (OTC).
- Basic instructions on how to use the tool kit and on reasons to seek care.
You might be hearing from your patients who are Empire members. If you have any questions, please contact Provider Services via the number on the back of the patient’s member ID card. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As you are aware, the federal Consolidated Appropriations Act (CAA) of 2021 contains several provisions applicable to health plans and their providers. One of the provisions is commonly referred to as a Gag Clause provision; specifically, Section 201: Increasing Transparency by Removing Gag Clauses on Price and Quality Information. Commercial health plans are required to attest annually that their provider agreements are in compliance with the Gag Clause provision. Should your provider agreement with Empire BlueCross (Empire) and Empire BlueCross BlueShield (Empire) have language inconsistent with the Gag Clause provision, it is deemed as null and void by Empire. To memorialize this provision in your provider agreement, we are providing a CAA Gag Clause Regulatory Addendum. Please attach this addendum to your provider agreement with Empire. Thank you for the care you provide our members — your patients. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting empireblue.com/provider, then under Provider Overview, select Find Care. Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance page on our website. Online update options include: - Add/change an address location.
- Name change.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. NYBCBS-CM-029084-23-SRS29062 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The provider manual has been updated for an effective date of November 1, 2023, and is now available on our website. To view the updated manual, go to anthem.com. Select For Providers and then under Provider Resources, select Policies, Guidelines and Manuals. Enter New York as state, scroll to Provider Manual and select Download the Manual. Select Preview the upcoming manual in the green box to view the provider manual effective November 1, 2023. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As we communicated in July, we will use the Provider Data Management (PDM) application on Availity Essentials* to verify and initiate care provider demographic change requests for all professional and facility care providers.** Going forward, Availity PDM is now the intake application for care providers to submit demographic change requests, including submitting roster uploads. Availity PDM will replace all current intake channels for demographic change requests and roster submissions as of October 1, 2023. If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. Take action nowDon’t wait until October to start using the PDM application. Start using it today to take advantage of the benefits of this application and familiarize yourself with the process before the legacy intake channels retire. What features does the Availity PDM application provide?It allows you to: - Update provider demographic information for all assigned payers in one location.
- Attest and manage current provider demographic information.
- Review the history of previously verified data.
Benefits to our care providers using Availity PDMThe Availity PDM application will ensure the following: - Consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
- Choice and flexibility to request data updates via the standard PDM experience or by submitting a spreadsheet via a roster upload
Want to submit a roster using Availity PDM?Don’t wait — Start submitting today. Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:*** - Utilize the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement:
- A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). Find it online here.
- Upload your completed roster via the Availity PDM application.
- Join our live webinar:
- Title of webinar: Roster Automation Template and Rules of Engagement Training
- Date: Monday, August 21, 2023
- Time: 4 to 5 p.m. ET
- Registration link: here
What about the previous methods by which I have been submitting information?While we are in the process of sunsetting our legacy intake channels, we will continue to process submissions received through current intake channels until September 30, 2023. Effective October 1, 2023, all PDM requests, including rosters, must be submitted via Availity PDM. As of this date, all provider demographic change requests, including rosters, will be rejected if submitted through any format/channel other than Availity PDM. Again, if preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. How to access the Availity PDM applicationLog onto availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts. Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Training is available: - Learn about and attend one of our training opportunities by visiting here.
- View the Availity PDM quick start guide here.
Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by logging into 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. If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY. Note: For national providers who provide services in multiple markets, California (all lines of business), Colorado (Commercial and Medicare), and Nevada (all lines of business) are not available for Availity PDM until our Strategic Provider System migration. ** Exclusions: - Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
- Any specific state mandates or requirements for provider demographic updates.
*** If any roster data updates require credentialing, your submission will be routed appropriately for further action. * Availity, LLC is an independent company providing administrative support services on behalf of health plan. Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CDCRCM-031757-23-CPN30214 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. OverviewWe’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. Engagement Hub objectives:- Learn strategies to help you and your care team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
- Offer care providers a convenient way to earn CME credits at a time that works best for them.
Browse the listing of free CME webinars.* * Sessions in this series are approved for one American Academy of Family Physicians credit each. NYBCBS-CRCM-030985-23-CPN29678 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. *Material
adverse change (MAC) On August 19, 2022, and March 23, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus (Empire). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: Newly published criteria
- Revised: Addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Empire only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | August 19, 2023 | *CC-0235 | Revcovi (elapegademase-lvlr) | New | August 19, 2023 | *CC-0236 | Signifor LAR (pasireotide) | New | August 19, 2023 | CC-0125 | Opdivo (nivolumab) | Revised | August 19, 2023 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | August 19, 2023 | CC-0038 | Human Parathyroid Hormone Agents | Revised | August 19, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | August 19, 2023 | *CC-0197 | Jemperli (dostarlimab-gxly) | Revised | August 19, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised | August 19, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised | August 19, 2023 | *CC-0065 | Hemophilia A and von Willebrand Disease | Revised | August 19, 2023 | *CC-0034 | Agents for Hereditary Angioedema | Revised | August 19, 2023 | CC-0008 | Subcutaneous Hormonal Implants | Revised | August 19, 2023 | CC-0026 | Testosterone, Injectable | Revised |
NYBCBS-CD-027398-23-CPN24610 Itemized Bill Review program Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. IntroductionWe are publishing this clarification based on the increase in questions recently received regarding the itemized bill review (IBR) program conducted by our vendor-partner, CERiS.* This section includes guidelines on reimbursement to Providers and Facilities for services on claims paid by DRG with an outlier paid at percent of billed charge or where the entire claim is paid at percent of billed charge. Our vendor-partner or our internal team may review these claims as part of our itemized bill review (IBR) program to ensure appropriate reimbursement. Documentation, including a summary of adjusted charges, will be provided for each claim upon completion of the review. Disputes related to the review may be submitted according to the instructions in the documentation received upon completion of the review. In addition to any header in this section, please refer to all other service specific sections which may have more stringent guidelines. There may be multiple sections that apply to any given reimbursable service. Audits/reviews/records requestsAt any time, a request may be made for on-site, electronic or hard copy medical records, utilization review documentation, and/or itemized bills related to Claims for the purposes of conducting audits or reviews. Blood and blood productsAdministration of blood or blood products are not separately reimbursable on inpatient claims. Administration charges on outpatient claims are separately reimbursable when submitted without observation/treatment room charges. Charges for blood storage and processing, thawing fees charges, irradiation, and other processing charges, are also not separately reimbursable. Emergency room supplies and services charges The Emergency Room level reimbursement includes all monitoring, equipment, supplies, and time and staff charges. Reimbursement for the use of the Emergency Room includes the use of the room and personnel employed for the examination and treatment of patients. This reimbursement does not typically include the cost of physician services. Facility personnel charges Charges for Inpatient Services for Facility personnel are not separately reimbursable and the reimbursement for such is included in the room and board rate. Examples include, but are not limited to, lactation consultants, dietary consultants, overtime charges, transport fees, nursing functions (including IV or PICC line insertion at bedside), professional therapy functions, including Physical, Occupational, and Speech call back charges, nursing increments, therapy increments, and bedside respiratory and pulmonary function services. Charges for Outpatient Services for facility personnel are also not separately reimbursable. The reimbursement is included in the payment for the procedure or Observation charge. Implants Implants are objects or materials which are implanted such as a piece of tissue, a tooth, a pellet of medicine, a medical device, a tube, a graft, or an insert placed into a surgically or naturally formed cavity of the human body to continuously assist, restore or replace the function of an organ system or structure of the human body throughout its useful life. Implants include, but are not limited to: stents, artificial joints, shunts, pins, plates, screws, anchors and radioactive seeds, in addition to non-soluble, or solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed. Instruments that are designed to be removed or discarded during the same operative session during which they are placed in the body are not implants. In addition to meeting the above criteria, implants must also remain in the member's body upon discharge from the inpatient stay or outpatient procedure. Staples, sutures, clips, as well as temporary drains, tubes, similar temporary medical devices and supplies shall not be considered implants. Implants that are deemed contaminated and/or considered waste and/or were not implanted in the Member will not be reimbursed. IV sedation and local anesthesia Charges for IV sedation and local anesthesia administered by the provider performing the procedure, and/or nursing personnel, is not separately reimbursable and is included as part of the Operating Room (OR) time/procedure reimbursement. Medications used for IV sedation and local anesthesia are separately reimbursable. Lab charges The reimbursement of charges for specimen collection are considered facility personnel charges and the reimbursement is included in the room and board or procedure/Observation charges. Examples include venipuncture, urine/sputum specimen collection, draw fees, phlebotomy, heel sticks, and central line draws. Processing fees, handling fees, and referral fees are considered included in the procedure/lab test performed and not separately reimbursable. Labor care charges Reimbursement will be made for appropriately billed room and board or labor charges. Payment will not be made on both charges when billed concurrently. Nursing procedures Fees associated with nursing procedures or services provided by facility nursing staff or unlicensed Facility personnel (technicians) performed during an inpatient (IP) admission or outpatient (OP) visit will not be reimbursed separately. Examples include, but are not limited, to intravenous (IV) injections or IV fluid administration/monitoring, intramuscular (IM) injections, subcutaneous (SQ) injections, IV or PICC line insertion at bedside, nasogastric tube (NGT) insertion, urinary catheter insertion, point of care/bedside testing (such as glucose, blood count, arterial blood gas, clotting time, etc.) and inpatient blood transfusion administration/monitoring (with the exception of OP blood administration or OP chemotherapy administration which are submitted without observation/treatment room charges.) Operating room time and procedure chargesThe operating room (OR) charge will be based on a time or procedural basis. When time is the basis for the charge, it should be calculated from the time the patient enters the room until the patient leaves the room, as documented on the OR nurse’s notes. The operating room charge will reflect the cost of: - The use of the operating room
- The services of qualified professional and technical personnel
Personal care items and servicesPersonal care items used for patient convenience are not separately reimbursable. Examples include but are not limited to: breast pumps, deodorant, dry bath, dry shampoo, lotion, non-medical personnel, mouthwash, powder, soap, telephone calls, television, tissues, toothbrush and toothpaste, bedpans, chux, hot water bottles, icepacks, pillows, sitz baths, and urinals. Pharmacy charges Reimbursement will be made for the cost of drugs prescribed by the attending physician. Additional separate charges for the administration of drugs, the cost of materials necessary for the preparation and administration of drugs, and the services rendered by registered pharmacists and other pharmacy personnel will not be reimbursed separately. All other services are included in the drug reimbursement rate. Example of pharmacy charges which are not separately reimbursable include, but are not limited to: IV mixture fees, IV diluents such as saline and sterile water, IV Piggyback (IVPB), Heparin and saline flushes to administer IV drugs, and facility staff checking the pharmacy (Rx) cart. Portable charges Portable Charges are included in the reimbursement for the procedure, test, or x-ray, and are not separately reimbursable. Pre-operative care or holding room charges Charges for a pre-operative care or a holding room used prior to a procedure are included in the reimbursement for the procedure and are not separately reimbursed. In addition, nursing care provided in the pre-operative care areas will not be reimbursed separately. Preparation (set-up) charges Charges for set-up, equipment, or materials in preparation for procedures or tests are included in the reimbursement for that procedure or test. Recovery room charges Reimbursement for recovery room services (time or flat fee) includes the use of all and/or available services, equipment, monitoring, and nursing care that is necessary for the patient’s welfare and safety during his/her confinement. This will include but is not limited to cardiac/vital signs monitoring, pulse oximeter, medication administration fees, nursing services, equipment, supplies, (whether disposable or reusable), defibrillator, and oxygen. Separate reimbursement for these services will not be made. Recovery room services related to IV sedation and/or local anesthesia Separate reimbursement will not be made for a phase I or primary recovery room charged in connection with IV sedation or local anesthesia. Charges will be paid only if billed as a post procedure room or a phase II recovery (step-down) Examples of procedures include arteriograms and cardiac catheterization. Supplies and servicesItems used for the patient which are needed as a direct result of a procedure or test are considered part of the room and board or procedure charges and are not separately reimbursable. Any supplies, items, and services that are necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine services and not separately reimbursable in the inpatient and outpatient environments. Special procedure room charge Special procedure room charges are included in the reimbursement for the procedure. If the procedure takes place outside of the OR suite, then OR time will not be reimbursed to cover OR personnel/staff being present in the room. Example: ICU, GI lab, etc. Stand-by charges Standby equipment and consumable items which are on standby, are not reimbursable. Standby charges for facility personnel are included in the reimbursement for the procedure and not separately reimbursable. Stat charges Stat charges are included in the reimbursement for the procedure, test, and/or X-ray. These charges are not separately reimbursable. Supplies and equipment Charges for medical equipment, including but not limited to, IV pumps, PCA Pumps, Oxygen, and isolation carts and supplies are not separately reimbursable. Telemetry Telemetry charges in ER/ ICU/CCU/NICU or telemetry unit (step-down units) are included in the reimbursement for the place of service. Additional monitoring charges are not reimbursable. Time calculation- Operating Room (OR) –Time should be calculated on the time the patient enters the room until the patient leaves the room, as documented on the OR nurse’s notes.
- Hospital/ Technical Anesthesia - Reimbursement of technical anesthesia time will be based on the time the patient enters the operating room (OR) until the patient leaves the room, as documented on the OR nurse’s notes. The time the anesthesiologist spends with the patient in pre-op and the recovery room will not be reimbursed as part of the hospital anesthesia time.
- Recovery Room – The reimbursement of Recovery Room charges will be based on the time the patient enters the recovery room until the patient leaves the recovery room as documented on the post anesthesia care unit (PACU) record.
- Post Recovery Room – Reimbursement will be based on the time the patient leaves the Recovery Room until discharge.
Video or digital equipment used in operating room Charges for video or digital equipment used in a surgery are included in the reimbursement for the procedure and are not separately reimbursable. Charges for batteries, covers, film, anti-fogger solution, tapes etc., are not separately reimbursable. Additional reimbursement guidelines for disallowed chargesThe disallowed charges (charges not eligible for reimbursement) include, but are not limited to, the following, whether billed under the specified Revenue Code or any other Revenue Code. These Guidelines may be superseded by your specific agreement. Please refer to your contractual fee schedule for payment determination. The tables below illustrate examples of non-reimbursable items/services codes. Examples of non-reimbursable items/services codes | | Typically billed under this/these revenue codes but not limited to the revenue codes listed below | Description of excluded items | 0990 – 0999 | Personal Care Items - Courtesy/Hospitality Room
- Patient Convenience Items (0990)
- Cafeteria, Guest Tray (0991)
- Private Linen Service (0992)
- Telephone, Telegraph (0993)
- TV, Radio (0994)
- Non-patient Room Rentals (0995)
- Beauty Shop, Barber (0998)
- Other Patient Convenience Items (0999)
| 0220 | Special Charges | 0369 | Preoperative Care or Holding Room Charges | 0760 – 0769 | Special Procedure Room Charge | 0111 – 0119 | Private Room* (subject to Member’s Benefit) | 0221 | Admission Charge | 0480 – 0489 | Percutaneous Transluminal Coronary Angioplasty (PTCA) Stand-by Charges | 0220, 0949 | Stat Charges | 0270 – 0279, 0360 | Video Equipment Used in Operating Room | 0270, 0271, 0272 | Supplies and Equipment - Blood Pressure cuffs/Stethoscopes
- Thermometers, Temperature Probes, etc.
- Pacing Cables/Wires/Probes
- Pressure/Pump Transducers
- Transducer Kits/Packs
- SCD Sleeves/Compression Sleeves/Ted Hose
- Oximeter Sensors/Probes/Covers
- Electrodes, Electrode Cables/Wires
- Oral swabs/toothettes;
- Wipes (baby, cleansing, etc.)
- Bedpans/Urinals
- Bed Scales/Alarms
- Specialty Beds
- Foley/Straight Catheters, Urometers/Leg Bags/Tubing
- Specimen traps/containers/kits
- Tourniquets
- Syringes/Needles/Lancets/Butterflies
- Isolation carts/supplies
- Dressing Change Trays/Packs/Kits
- Dressings/Gauze/Sponges
- Kerlix/Tegaderm/OpSite/Telfa
- Skin cleansers/preps
- Cotton Balls; Band-Aids, Tape, Q-Tips
- Diapers/Chucks/Pads/Briefs
- Irrigation Solutions
- ID/Allergy bracelets
- Foley stat lock
- Gloves/Gowns/Drapes/Covers/Blankets
- Ice Packs/Heating Pads/Water Bottles
- Kits/Packs (Gowns, Towels and Drapes)
- Basins/basin sets
- Positioning Aides/Wedges/Pillows
- Suction Canisters/Tubing/Tips/Catheters/Liners
- Enteral/Parenteral Feeding Supplies (tubing/bags/sets, etc.)
- Preps/prep trays
- Masks (including CPAP and Nasal Cannulas/Prongs)
- Bonnets/Hats/Hoods
- Smoke Evacuator Tubing
- Restraints/Posey Belts
- OR Equipment (saws, skin staplers, staples & staple removers, sutures, scalpels, blades etc.)
- IV supplies (tubing, extensions, angio-caths, stat-locks, blood tubing, start kits, pressure bags, adapters, caps, plugs, fluid warmers, sets, transducers, fluid warmers, heparin and saline flushes, etc.)
| 0220 – 0222, 0229, 0250 | - · Pharmacy Administrative Fee (including mixing meds)
- · Portable Fee (cannot charge portable fee unless equipment is brought in from another Facility)
- · Patient transport fees
| 0223 | Utilization Review Service Charges | 263 | IV Infusion for therapy, prophylaxis (96365, 96366) IV Infusion additional for therapy IV Infusion concurrent for therapy (96368) IV Injection (96374, 96379) | 0230, 0270 – 0272, 0300 – 0307, 0309, 0390-0392, 0310 | Nursing Procedures | 0230 | Incremental Nursing – General | 0231 | Nursing Charge – Nursery | 0232 | Nursing Charge – Obstetrics (OB) | 0233 | Nursing Charge – Intensive Care Unit (ICU) | 0234 | Nursing Charge – Cardiac Care Unit (CCU) | 0235 | Nursing Charge – Hospice | 0239 | Nursing Charge – Emergency Room (ER) or Post Anesthesia Care Unit (PACU) or Operating Room (OR) | 0250 – 0259, 0636 | Pharmacy (non-formulary drugs, compounding fees, nonspecific descriptions) - · Medication prep
- · Nonspecific descriptions
- · Anesthesia Gases – Billed in conjunction with Anesthesia Time Charges
- · IV Solutions 250 cc or less, except for pediatric claims
- · Miscellaneous Descriptions
- · Non-FDA Approved Medications
| 0270, 0300 – 0307, 0309, 0380 – 0387,
0390 – 0392 | - Specimen collection
- Draw fees
- Venipuncture
- Phlebotomy
- Heel stick
- Blood storage and processing blood administration (Rev codes 0380, 0390 – 0392; 0399)
- Thawing/Pooling Fees
| 0270, 0272, 0300 – 0309 | - Bedside/Point of Care/Near Patient Testing (such as glucose, blood count, arterial blood gas, clotting time, glucose, etc.)
| 0222, 0270, 0272, 0410, 0460 | Portable Charges | 0270 – 0279, 0290, 0320, 0410, 0460 | Supplies and Equipment - · Oxygen
- · Instrument Trays and/or Surgical Packs
- · Drills/Saws (All power equipment used in O.R.)
- · Drill Bits
- · Blades
- · IV pumps and PCA (Patient Controlled Analgesia) pumps
- · Isolation supplies
- · Daily Floor Supply Charges
- · X-ray Aprons/Shields
- · Blood Pressure Monitor
- · Beds/Mattress
- · Patient Lifts/Slings
- · Restraints
- · Transfer Belt
- · Bair Hugger Machine/Blankets
- · SCD Pumps
- · Heal/Elbow Protector
- · Burrs
- · Cardiac Monitor
- · EKG Electrodes
- · Vent Circuit
- · Suction Supplies for Vent Patient
- · Electrocautery Grounding Pad
- · Bovie Tips/Electrodes
- · Anesthesia Supplies
- · Case Carts
- · C-Arm/Fluoroscopic Charge
- · Wound Vacuum Pump
- · Bovie/Electro Cautery Unit
- · Wall Suction
- · Retractors
- · Single Instruments
- Oximeter Monitor
- CPM Machines
- Lasers
- Da Vinci Machine/Robot
| 0370 – 0379, 0410, 0460, 0480 – 0489 | Anesthesia - · Nursing care
- · Monitoring
- · Intervention
- · Pre- or Post-evaluation and education
- · IV sedation and local anesthesia if provided by RN
- · Intubation/Extubation
- · CPR
| | 410 | Respiratory Functions: - Oximetry reading by nurse or respiratory
- Respiratory assessment/vent management
- Medication Administration via Nebs, Metered dose (MDI), etc.
- Charges Postural Drainage
- Suctioning Procedure
- Respiratory care performed by RN
| | 0940 – 0945 | Education/Training | |
* CERiS is an independent company providing administrative support services on behalf of the health plan. NYBCBS-CR-028160-23 Clinical Criteria updates Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. *Material
adverse change (MAC) On August 19, 2022, and March 23, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield (Empire). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: Newly published criteria
- Revised: Addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in your practice and office staff. Please note:- The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Empire only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | August 6, 2023 | *CC-0235 | Revcovi (elapegademase-lvlr) | New | August 6, 2023 | *CC-0236 | Signifor LAR (pasireotide) | New | August 6, 2023 | CC-0125 | Opdivo (nivolumab) | Revised | August 6, 2023 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | August 6, 2023 | CC-0038 | Human Parathyroid Hormone Agents | Revised | August 6, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | August 6, 2023 | *CC-0197 | Jemperli (dostarlimab-gxly) | Revised | August 6, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised | August 6, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised | August 6, 2023 | *CC-0065 | Hemophilia A and von Willebrand Disease | Revised | August 6, 2023 | *CC-0034 | Agents for Hereditary Angioedema | Revised | August 6, 2023 | CC-0061 | GnRH Analogs for the Treatment of Non-Oncologic Indications | Revised | August 6, 2023 | CC-0008 | Subcutaneous Hormonal Implants | Revised | August 6, 2023 | CC-0026 | Testosterone, Injectable | Revised |
NYBCBS-CR-027359-23-CPN26411 Clinical Appropriateness Guidelines 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 November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Joint Surgery updates by sectionMultiple joints:- Loose body — Added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
- Synovectomy — Added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee
Shoulder:- Rotator cuff repair — Modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
- Revision rotator cuff repair — Added exclusion for patients with rotator cuff arthropathy
- Labrum repair — Broadened MRI findings to allow for any labral tear other than a Bankart lesion
- Adhesive capsulitis — Extended required conservative management from six weeks to 12 weeks
- Capsulorraphy — Added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
- Subacromial decompression/acromioplasty — Added indications for symptomatic is acromial and for symptomatic mechanical impingement due to tumor or malunited fracture
- Shoulder debridement — Extended required conservative management to 12 weeks
- Biceps tenodesis/tenotomy — Broadened criteria to allow when criteria are met for any shoulder procedure, or when patient has an acute proximal biceps tear
- Added exclusion for subacromial balloon spacer and for shoulder resurfacing
Hip:- Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
- Revision total hip arthroplasty — Added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
- Acetabuloplasty — Added indications for arthritis, hip instability, and FAIS
- Diagnostic arthroscopy — Added exclusion for non-intra-articular hip procedures
- Femoroacetabular impingement syndrome (FAIS) — Specified requirement for alpha angle greater than 55 degrees for femoroplasty
- Labral tear — Added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
- Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia
Knee:- Total knee arthroplasty — Added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
- Unicompartmental knee arthroplasty — Modified requirements related to conservative management and varus/valgus deformities; allow concurrent ACL reconstruction in some scenarios
- Revision knee arthroplasty — Added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
- Abrasion arthroplasty/microfracture — Aligned with osteochondral grafts criteria regarding the size of defect that can be treated
- Debridement/drainage/lavage (knee) — Reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
- Anterolateral ligament reconstruction or extra-articular tenodesis — Added indications
- ACL reconstruction and PCL repair/reconstruction — Excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
- Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
- Patellar compression syndrome — Added exclusion for central or medial tracking of the patella
- Medial patellofemoral ligament reconstruction — Waived requirement for conservative management when function is limited due to pain
Osteochondral grafts:- Patient selection requirements — Specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
- Osteochondritis dissecans — Added indications for surgical treatment
- Osteochondral allograft transplantation — Decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee
- Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
- HCPCS code added: S2118
Small Joint Surgery:- Hallux rigidus procedures; hallux valgus and bunionette procedures; lesser toe deformities — Removed poor wound healing as a contraindication
- Hallux valgus surgery — Add allowance for pre-ulcer (Wagner grade 0 to 1 lesion); added criterion for simple exostectomy/resection medial eminence; separated bunionette surgery indications from hallux valgus surgery
- First MTP joint arthrodesis for hallux valgus — Added indication
- Metatarsal osteotomy — Separated criteria into standalone indication; added exclusion for improved cosmesis
- Ankle arthritis — Added indication for revision total ankle arthroplasty
- Ankle arthroplasty — Removed severe ankle deformity and peripheral neuropathy as contraindications
Level of Care for Musculoskeletal Surgery:- Added total or partial primary shoulder arthroplasty to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty
- CPT® codes added to level of care review: 23470 and 23472
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by: - Accessing Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com:
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CM-027321-23-CPN26945 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As communicated in the July Provider Newsletter, effective October 1, 2023, Carelon Medical Benefits Management, Inc. * a specialty health benefits company, will perform medical necessity reviews for procedures for Empire BlueCross BlueShield (Empire) members, as outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable. The expansion will require clinical appropriateness review for pacemakers as part of the Carelon Medical Benefits Management Cardiology program. Due to CPT® code overlap, management of ICD and CRT devices without inclusion of pacemakers creates provider abrasion and operational challenges. The clinical guidelines and medical policies that have been adopted by Empire to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 18, 2023, for dates of service October 1, 2023, and after. Members included in the new programAll fully insured, self-funded (ASO), and National members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of August 1, 2023. Members of the following products are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and Federal Employee Program® (FEP®). Pre-service review requirementsFor procedures that are scheduled to begin on or after October 1, 2023, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following non-emergency modalities. Please refer to the clinical guidelines at the links below for more details including code lists. Leadless pacemakers medical policy related to the insertion, removal, or replacement of permanent leadless pacemakers. Carelon Medical Benefits Management permanent implantable pacemakers clinical appropriateness guideline related to insertion, repair, removal, repositioning, or replacement of permanent implantable pacemakers, pacemaker pulse generators, or electrodes. To determine if prior authorization is needed for a member on or after October 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials* website to pre-certify an outpatient procedure, will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.) Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com to register. For more informationGo to providers.carelonmedicalbenefitsmanagement.com/cardiology for resources to help your practice get started with the Cardiology program. Our special websites help you learn more and access 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. *Carelon Medical Benefits Management, Inc. is an independent company providing administrative support services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan. NYBCBS-CM-028687-23- CPN28575 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 November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management Guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Joint surgery updates by section:- Multiple joints:
- Loose body — added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
- Synovectomy — added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee
- Shoulder:
- Rotator cuff repair — modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
- Revision rotator cuff repair — added exclusion for patients with rotator cuff arthropathy
- Labrum repair — broadened MRI findings to allow for any labral tear other than a Bankart lesion
- Adhesive capsulitis — extended required conservative management from six weeks to 12 weeks
- Capsulorraphy — added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
- Subacromial decompression/acromioplasty — added indications for symptomatic os acromiale and for symptomatic mechanical impingement due to tumor or malunited fracture
- Shoulder debridement — extended required conservative management to 12 weeks
- Biceps tenodesis/tenotomy — broadened criteria to allow when criteria are met for any shoulder procedure or when patient has an acute proximal biceps tear
- Added exclusion for subacromial balloon spacer and for shoulder resurfacing
- Hip:
- Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
- Revision total hip arthroplasty — added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
- Acetabuloplasty — added indications for arthritis, hip instability, and FAIS
- Diagnostic arthroscopy — added exclusion for non-intra-articular hip procedures
- Femoroacetabular impingement syndrome (FAIS) — specified requirement for alpha angle greater than 55 degrees for femoroplasty
- Labral tear — added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
- Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia
- Knee:
- Total knee arthroplasty — added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
- Unicompartmental knee arthroplasty — modified requirements related to conservative management and varus/valgus deformities; allow concurrent anterior cruciate ligament (ACL) reconstruction in some scenarios
- Revision knee arthroplasty — added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
- Abrasion arthroplasty/microfracture — aligned with osteochondral grafts criteria regarding the size of defect that can be treated
- Debridement/drainage/lavage (knee) — reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
- Anterolateral ligament reconstruction or extra-articular tenodesis — added indications
- ACL reconstruction and posterior cruciate ligament (PCL) repair/reconstruction — excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
- Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
- Patellar compression syndrome — added exclusion for central or medial tracking of the patella
- Medial patellofemoral ligament reconstruction — waived requirement for conservative management when function is limited due to pain
- Osteochondral grafts:
- Patient selection requirements — specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
- Osteochondritis dissecans — added indications for surgical treatment
- Osteochondral allograft transplantation — decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee
- Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
Level of care for musculoskeletal (MSK) surgery:- Added “total or partial primary shoulder arthroplasty” to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty
- CPT® codes added to level of care review: 23470 and 23472
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Via Availity Essentials* at availity.com.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.Availity, LLC is an independent company providing administrative support services on behalf of the health plan. NYBCBS-CR-027332-23-CPN26944 Medical Policies and Clinical Utilization Management Guidelines Update Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please share this notice with other providers in your practice and office staff. To view a guideline, visit empireblue.com/provider/policies/clinical-guidelines/search/. Notes/updates:Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive: - MED.00145 - Digital Therapy Devices for Treatment of Amblyopia:
- Digital therapy devices for treatment of amblyopia are considered Investigational & Not Medically Necessary
- CG-LAB-26 - Outpatient Alpha-Fetoprotein Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for outpatient alpha-fetoprotein testing
- CG-LAB-27 - Human Chorionic Gonadotropin Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for laboratory testing of human chorionic gonadotropin (hCG)
- CG-LAB-28 - Prostate Specific Antigen Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for prostate specific antigen (PSA) testing
- CG-SURG-18 – Septoplasty:
- Re-formatted hierarchy in Clinical Indications section
- Revised Medically Necessary criteria related to conservative management
- Revised “chronic recurrent sinusitis” to “chronic or recurrent acute sinusitis”
- Revised Not Medically Necessary statement to remove bulleted list below statement
Carelon Medical Benefits Management, Inc.* updatesEffective for dates of service on and after August 1, 2023, MRI of the Breast – RAD.00036 is transitioning to Carelon Medical Benefits Management, Inc. criteria in the following two guidelines: - Imaging of the chest
- Oncologic imaging
Medical PoliciesOn February 16, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire). These guidelines take effect August 6, 2023. Publish Date | Medical Policy Number | Medical Policy Title | New or Revised | 2/23/2023 | GENE.00049 | Circulating Tumor DNA Panel Testing (Liquid Biopsy) | Revised | 4/12/2023 | *MED.00145 | Digital Therapy Devices for Treatment of Amblyopia | New | 3/29/2023 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Revised | 4/12/2023 | SURG.00103 | Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) | Revised |
Clinical UM GuidelinesOn February 16, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines were adopted by the medical operations committee for Medicaid members on March 23, 2023. These guidelines take effect August 6, 2023. Publish Date | Clinical UM Guideline Number | Clinical UM Guideline Title | New or Revised | 4/12/2023 | *CG-LAB-26 | Outpatient Alpha-Fetoprotein Testing | New | 4/12/2023 | *CG-LAB-27 | Human Chorionic Gonadotropin Testing | New | 4/12/2023 | *CG-LAB-28 | Prostate Specific Antigen Testing | New | 2/23/2023 | CG-SURG-106 | Venous Angioplasty with or without Stent Placement or Venous Stenting Alone | Revised | 2/23/2023 | CG-SURG-115 | Mechanical Embolectomy for Treatment of Stroke | Revised | 4/12/2023 | CG-SURG-117 | Balloon Dilation of the Eustachian Tubes | New | 4/12/2023 | *CG-SURG-18 | Septoplasty | Revised | 4/12/2023 | CG-SURG-46 | Myringotomy and Tympanostomy Tube Insertion | Revised |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CD-025324-23-CPN24966 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 November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management Guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Joint surgery updates by section:- Multiple joints:
- Loose body — added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
- Synovectomy — added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee
- Shoulder:
- Rotator cuff repair — modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
- Revision rotator cuff repair — added exclusion for patients with rotator cuff arthropathy
- Labrum repair — broadened MRI findings to allow for any labral tear other than a Bankart lesion
- Adhesive capsulitis — extended required conservative management from six weeks to 12 weeks
- Capsulorraphy — added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
- Subacromial decompression/acromioplasty — added indications for symptomatic os acromiale and for symptomatic mechanical impingement due to tumor or malunited fracture
- Shoulder debridement — extended required conservative management to 12 weeks
- Biceps tenodesis/tenotomy — broadened criteria to allow when criteria are met for any shoulder procedure or when patient has an acute proximal biceps tear
- Added exclusion for subacromial balloon spacer and for shoulder resurfacing
- Hip:
- Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
- Revision total hip arthroplasty — added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
- Acetabuloplasty — added indications for arthritis, hip instability, and FAIS
- Diagnostic arthroscopy — added exclusion for non-intra-articular hip procedures
- Femoroacetabular impingement syndrome (FAIS) — specified requirement for alpha angle greater than 55 degrees for femoroplasty
- Labral tear — added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
- Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia
- Knee:
- Total knee arthroplasty — added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
- Unicompartmental knee arthroplasty — modified requirements related to conservative management and varus/valgus deformities; allow concurrent anterior cruciate ligament (ACL) reconstruction in some scenarios
- Revision knee arthroplasty — added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
- Abrasion arthroplasty/microfracture — aligned with osteochondral grafts criteria regarding the size of defect that can be treated
- Debridement/drainage/lavage (knee) — reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
- Anterolateral ligament reconstruction or extra-articular tenodesis — added indications
- ACL reconstruction and posterior cruciate ligament (PCL) repair/reconstruction — excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
- Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
- Patellar compression syndrome — added exclusion for central or medial tracking of the patella
- Medial patellofemoral ligament reconstruction — waived requirement for conservative management when function is limited due to pain
- Osteochondral grafts:
- Patient selection requirements — specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
- Osteochondritis dissecans — added indications for surgical treatment
- Osteochondral allograft transplantation — decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee
- Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
Level of care for musculoskeletal (MSK) surgery:- Added “total or partial primary shoulder arthroplasty” to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty
- CPT® codes added to level of care review: 23470 and 23472
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Via Availity Essentials* at availity.com.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.Availity, LLC is an independent company providing administrative support services on behalf of the health plan. NYBCBS-CD-027331-23-CPN26944 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective November 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Empire BlueCross BlueShield (Empire) for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Code description | 0377U | Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile | 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and | 0687T | Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session | 0688T | Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report | 0704T | Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment | 0705T | Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hour | 0706T | Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month | 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle | A2019 | Kerecis omega3 marigen shield, per square centimeter | A2020 | Ac5 advanced wound system (ac5) | A2021 | Neomatrix, per square centimeter | A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each | A4342 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each | E1905 | Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software | Q4265 | Neostim tl, per square centimeter | Q4266 | Neostim membrane, per square centimeter | Q4267 | Neostim dl, per square centimeter | Q4268 | Surgraft ft, per square centimeter | Q4269 | Surgraft xt, per square centimeter | Q4270 | Complete sl, per square centimeter | Q4271 | Complete ft, per square centimeter |
Not all PA requirements are listed here. Detailed PA requirements are available to providers at empireblue.com/provider/news/archives/ > Providers > Claims > Prior Authorizations or for contracted providers by accessing Availity.com.* UM AROW 4505
*Availity, LLC is an independent company providing administrative support services on behalf of the health plan. NYBCBS-CR-028195-23-CPN27641 New specialty pharmacy medical step therapy requirements Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This is a correction to an article that was posted on August 1, 2023. The effective date was listed as July 1, 2023, in error. The correct effective date is October 1, 2023. Effective for dates of service on and after October 1, 2023, 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. Step therapy review will apply upon prior authorization initiation or renewal, in addition to the current medical necessity review of all drugs noted below. Clinical Criteria CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro, and the biosimilar Udenyca. This update is to provide notification that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as non-preferred agents. The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria. Clinical Criteria | Status | Drug(s) | HCPCS codes | CC-0002 | Non-preferred | Fulphila | Q5108 | CC-0002 | Non-preferred | Fylnetra | Q5130 | CC-0002 | Non-preferred | Nyvepria | Q5122 | CC-0002 | Non-preferred | Rolvedon | J1449 | CC-0002 | Non-preferred | Stimufend | Q5127 | CC-0002 | Non-preferred | Ziextenzo | Q5120 | CC-0002 | Preferred | Neulasta | J2506 | CC-0002 | Preferred | Neulasta OnPro | J2506 | CC-0002 | Preferred | Udenyca | Q5111 |
NYBCBS-CD-023950-23-CPN23712 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after November 1, 2023, Empire BlueCross BlueShield will update the Virtual Visits – Professional and Facility reimbursement policy to indicate that services reported by a professional provider with a place of service 02 (telehealth provided other than in patient’s home) or 10 (telehealth provided in patient’s home) will be eligible for non-office place of service reimbursement. For specific policy details, visit the reimbursement policy page. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Policy Update
Robotic Assisted Surgery(Policy G-10004, effective 11/01/2023) Beginning with dates of service on or after November 1, 2023, Robotic Assisted Surgery reimbursement policy for Empire BlueCross BlueShield HealthPlus will expand to include CPT® codes for computer-assisted surgical systems. This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed. The Related Coding section of the policy has been updated to include the following computer assisted surgical musculoskeletal navigation procedures: - 0054T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (list separately in addition to code for primary procedure)
- 0055T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (list separately in addition to code for primary procedure)
The policy has been renamed to Technology Assisted Surgical Procedures which defines both robotic assisted and computer assisted techniques. For additional information, please review the Technology Assisted Surgical Procedures reimbursement policy at https://providerpublic.empireblue.com. NYBCBS-CD-023730-23-CPN22827 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Informational Robotic Assisted Surgery(Policy G-10004, effective 09/01/2023) Effective September 1, 2023, the Robotic Assisted Surgery reimbursement policy with Empire BlueCross BlueShield will expand to include the computer-assisted surgical systems. This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure and are not separately reimbursed. The policy has been renamed to Technology Assisted Surgical Procedures defines both robotic assisted and computer assisted techniques. For additional information, please review the Technology Assisted Surgical Procedures reimbursement policy at https://www.empireblue.com/medicareprovider. NYBCBS-CR-023731-23-CPN22827 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective June 14, 2023, Empire BlueCross BlueShield’s split care surgical modifier language was removed from the Global Surgical Package — Professional reimbursement policy and added to a new standalone reimbursement policy titled Split Care Surgical Modifiers — Professional. This policy allows reimbursement based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. The percentage is determined by the modifier that is appended to the procedure code. The Related Coding section of the policy identifies the applicable modifiers and standard reimbursement percentages. For specific policy details, visit the reimbursement policy page. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Your Dual-Eligible Special Needs Plan (DSNP) member’s Individualized Care Plan (ICP/CP) is available on Availity* at www.availity.com. We would like the opportunity to discuss identified problems/needs and collaborate on ways to assist the member in meeting their care plan goals. The member and/or caregiver are central to the process and are also invited to attend the Interdisciplinary Care Team (ICT) meeting. Your participation is important. If you would like to participate in the ICT meeting, call us back as soon as possible at 844-408-6568. When contacting us, include the member’s name, date of birth, and Medicare identification number. The case manager will reach out to set up the meeting. Any care plan changes made from the ICT meeting will be available for you to review on Availity one-to-two working days after the meeting. To access the care plan information, your Availity administrator must register you for access to Member Clinical Reports and complete the registration process using Payer Spaces > Preference Center. Once the registration piece is complete, log in to Availity, select Payer Spaces > Payer Tile > Alerts Hub to access the member’s ICP. We are available Monday through Friday, 8 a.m. to 5 p.m., excluding holidays. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. NYBCBS-CR-024220-23-CPN23812 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Specialty pharmacy updates for Empire BlueCross BlueShield (Empire) are listed below. Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.* 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. Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. Prior authorization updatesEffective for dates of service on and after November 1, 2023, 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) | CC-0237 | Qalsody (tofersen) | J3490, J3590 | CC-0240* | Zynyz (retifanlimab-dlwr) | J9999 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updatesWe are excited to announce the publication of a Medical Step Therapy Drug List. This list serves as an easy to access reference of the preferred and non-preferred products for each of the specialty pharmacy step therapy categories. The link to the pdf document is on the Clinical Criteria homepage. Access our Clinical Criteria to view the Medical Step Therapy Drug List. Quantity limit updatesEffective for dates of service on and after November 1, 2023, 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) | CC-0237 | Qalsody (tofersen) | J3490, J3590 | CC-0240 | Zynyz (retifanlimab-dlwr) | J9999 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CM-030319-23-CPN29780 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This article originally published with October 1, 2023 effective date in error. This requirement will not go into effect until December 1, 2023. Specialty pharmacy updates for Empire BlueCross BlueShield (Empire) are listed below. Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* 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. Including the National Drug Code (NDC) code on your claim may 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 December 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Note: On April 6, 2023, the FDA announced its decision to withdraw approval of Makena and generic versions of Makena for reducing the risk of pre-term birth because these drugs are no longer shown to be effective. Access our Clinical Criteria to view the complete information for these site of prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0238* | hydroxyprogesterone caproate | J1729 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CM-027438-23-CPN27209 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Empire BlueCross BlueShield (Empire) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by the Medical Specialty Drug Review team of Empire. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc.* a separate company. The following Clinical Criteria documents were endorsed at the May 19, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link. New Clinical Criteria effective November 1, 2023The following Clinical Criteria is new: - CC-0240 Zynyz (retifanlimab-dlwr)
Revised Clinical Criteria effective November 1, 2023The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary: - CC-0032 Botulinum Toxin
- CC-0057 Krystexxa (pegloticase)
- CC-0068 Growth Hormone
- CC-0124 Keytruda (pembrolizumab)
- CC-0125 Opdivo (nivolumab)
- CC-0225 Tzield (teplizumab-mzwv)
* Carelon Medical Benefits Management, Inc. is an independent company providing some utilization review services on behalf of the health plan. NYBCBS-CM-028991-23 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Visit the Drug Lists page on our provider website at https://www.empireblue.com/ms/pharmacyinformation/home.html for more information about: - 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 the exchange, select Formulary and Pharmacy Information, and 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. NYBCBS-CM-018447-23, NYBCBS-CM-029029-23 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Did you know?For most conditions, medications need to be taken 80% or more of the time to see an improvement in clinical outcomes such as blood pressure, blood glucose, or cholesterol control. Knowing this, it’s not surprising there is a strong emphasis on medication adherence and proportion of days covered (PDC) for the medication adherence quality measures. Medications are the primary intervention in treating and preventing disease and require patients to take medications long term. Unrecognized non-adherence can lead to dose escalation or additional medication therapy, potentially leading to an increase in adverse events. In addition, not adherence leads to increased medical utilization and morbidity and mortality. Back to the basics: How can we close the adherence gap?- Know which patients are at risk for non-adherence:
- Cognitive Impairment
- Fear of side effects
- Too many medications
- History of non-adherence
- Lack of perceived benefit
- Confusion
- Transportation
- Cost
Consider medication non-adherence as a reason when a patient’s condition is not under control.
- Implement a standardized process to identify patients with non-adherence:
- Ask about adherence at every appointment.
- Incorporate patient questionnaires or targeted questions using open ended questions into existing workflows.
- Analyze non-adherence reporting or claims to identify patients.
- Together with the patient, tailor the solution to the patient’s needs or concerns:
- Simplify the medication regimen.
- Always educate patients on benefits and risks of taking or not taking their medications.
- Leverage real-time prescription benefit to select lower cost and formulary medications during the electronic prescribing process.
- Encourage CarelonRx, Inc.* Mail and prescribe extended day supply to prevent refill gaps, avoid long waits at the pharmacy, and minimize transportation barriers.
* CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.
References:
- Brown M, Sinsky CA. Medication Adherence. Improve Patient Outcomes and Reduce Costs. American Medical Association Steps Forward. 5 June 2015.https://edhub.ama-assn.org/steps-forward/module/2702595. Accessed 16 May 2023
- Eight reasons patients don’t take their medications. American Medication Association. Feb 22, 2023. Accessed May 17, 2023.https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications
- El Halabi J, Minteer W, Boehmer KR. Identifying and Managing Treatment Nonadherence. Medical Clinics of North America. 2022;106(4):615-626. doi:https://doi.org/10.1016/j.mcna.2022.02.003
- Gooptu A, Taitel M, Laiteerapong N, Press VG. Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications. Healthcare (Basel). 2021 Jul 31;9(8):976. doi: 10.3390/healthcare9080976..
- Kini V, Ho PM. Interventions to Improve Medication Adherence. JAMA. 2018;320(23):2461. doi: https://doi.org/10.1001/jama.2018.19271
NYBCBS-CR-027445-23-CPN27258 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Why it matters:- Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in individuals with diabetes.
- The 2019 ACC/AHA* guidelines recommend statin therapy for primary prevention of ASCVD in patients with diabetes mellitus, aged 40 to 75 years, regardless of estimated 10-year ASCVD risk.
- Statins are generally well-tolerated and safe drugs.
- Benefits of lowering LDL-C with statins far outweigh the likelihood of an adverse effect for most adults at elevated risk for ASCVD and secondary events.
* ACC/AHA- American College of Cardiology and American Heart Association Did you know? - Just over 50% of US adults who would benefit from cholesterol-lowering medications are taking them.
- Reducing LDL-C levels with statins by ~39 mg/dL can reduce heart disease and stroke risk by ~21%
Best practices:- Educate patients on increased risk of cardiovascular disease to understand the benefits of statins.
- Once stable on therapy, prescribe 90-day supply to prevent refill gaps in therapy.
- Consider home delivery through *CarelonRx Mail to avoid long waits at the pharmacy and minimize transportation barriers.
- If statin side effects occur, consider strategies to mitigate them while continuing a statin:
- Lower the dose.
- Intermittent dosing with rosuvastatin may benefit patients with previous statin intolerances.
- Try a brief period of discontinuation, then re-challenge with the same or different statin.
Statin formulary medications Statin therapy intensity | Drug name | Dosage | Low-intensity statin therapy | lovastatin | 20 mg | pravastatin | 10 mg to 20 mg | simvastatin | 10 mg | Moderate-intensity statin therapy | atorvastatin | 10 mg to 20 mg | rosuvastatin | 5 mg to 10 mg | simvastatin | 20 mg to 40 mg | pravastatin | 40 mg to 80 mg | lovastatin | 40 mg | High-intensity statin therapy | atorvastatin | 40 mg to 80 mg | rosuvastatin | 20 mg to 40 mg |
Note: Both pitavastatin (Livalo) 1 to 4 mg and fluvastatin 40 mg BID qualify as moderate-intensity; however, Livalo is non-formulary and fluvastatin is a more expensive agent with member copay (Tier 3 or 4). * CarelonRx, Inc. is an independent company providing pharmacy services on behalf of the health plan.
References:
- American Heart Association: 2021 heart disease and stroke statistics update fact sheet. Accessed 5/8/2023.https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2021-Heart-and-Stroke-Stat-Update/2021_heart_disease_and_stroke_statistics_update_fact_sheet_at_a_glance.pdf
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11). doi:https://doi.org/10.1161/cir.0000000000000678
- Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. The Lancet. 2016;388(10059):2532-2561. doi:https://doi.org/10.1016/s0140-6736(16)31357-5
- ElSayed NA, Aleppo G, Aroda VR, et al. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2023. Diabetes Care. 2022;46(Supplement_1):S158-S190. doi:https://doi.org/10.2337/dc23-s010
- Hla D, Jones R, Blumenthal RS, et al.Assessing severity of statin side effects: Fact vs fiction. American College of Cardiology. April 09, 2018. Accessed May 17, 2023.https://www.acc.org/latest-in-cardiology/articles/2018/04/09/13/25/assessing-severity-of-statin-side-effects
- Reston JT, Buelt A, Donahue MP, Neubauer B, Vagichev E, McShea K. Interventions to Improve Statin Tolerance and Adherence in Patients at Risk for Cardiovascular Disease. Annals of Internal Medicine. 2020;173(10):806-812. doi:https://doi.org/10.7326/m20-4680
NYBCBS-CR-026510-23-CPN26142 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire is committed to ensuring all our members have controlled blood pressure. We’re encouraging you to recheck any elevated readings taken at the start of the appointment again before the patient leaves, in hopes of obtaining a reading of less than 140/90 mmHg. If the second reading continues to be elevated, have the member return in a few weeks for a blood pressure recheck. We’ve created a guide to help incorporate this practice into your office’s daily workflow with minimal disruption to your day. You can find the Healthy Blood Pressure Recheck Guide here. Please join us in making 2023 our members’ happiest and healthiest year yet! NYBCBS-CDCR-023981-23-CPN23630 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The problemIn 2021, there were 2855 cases of congenital syphilis reported for a rate of 77.9 per 100,000 live births. From 2012 to 2021, the number of cases of congenital syphilis increased 754.8% (334 to 2855 cases), concurrent with a 676.2% increase (2.1 to 16.3 per 100,000 lives) in the rate of primary and secondary syphilis among women aged 15 to 44 years.1 Maternal syphilis is associated with a 21% increased risk for stillbirth, 6% increased risk for preterm delivery, and 9% increased risk for neonatal death.2 Optimal treatment of syphilis during pregnancy is estimated to reduce the risk of congenital syphilis by 98%, stillbirth by 82%, preterm birth by 64%, and neonatal mortality by 80%.3 Syphilis is treatable and curable with penicillin. One in two newborn syphilis cases in the United States occur due to gaps in testing and treatment during prenatal care.3 Congenital syphilis: missed prevention opportunities1
You can make a difference — screen appropriately2 and treat early4!Universal screening: All pregnant women at their first prenatal visit. Treat immediately. High risk screening: Twice in third trimester (28 weeks and at delivery). Ask, document, rescreen: - History of sex with multiple partners
- Sex in conjunction with drug use or transactional sex
- No prenatal care or late entry
- Methamphetamine or heroin use
- Unstable housing or homelessness
- Incarceration of the woman or her partner
- Prior syphilis diagnosis
High prevalence screening: Twice in third trimester (28 weeks and at delivery) for pregnant women who live in communities with high rates of syphilis. For more information, visit https://gis.cdc.gov/grasp/nchhstpatlas/maps.html. Do you know the law in your state? Check your state health department website for updated recommendations. Do you practice in a high prevalence area? Universal screening in the third trimester and at birth are recommended. 1 Centers for Disease Control and Prevention. 2021.Sexually Transmitted Disease Surveillance, 2021 (cdc.gov)cdc.gov/std/statistics/2021/default.htm.
2 Adhikari, Emily H. MD. Syphilis in Pregnancy. Obstetrics & Gynecology 135(5): p1121-1135, May 2020.
3 U.S. Department of Health and Human Services. 2020. Sexually Transmitted Infections National Strategic Plan for the United States: 2021–2025. Washington, DC.
4 Centers for Disease Control and Prevention. 2021.Syphilis - STI Treatment Guidelines (cdc.gov)cdc.gov/std/treatmentguidelines/syphilis.htm. NYBCBS-CDCM-025843-23-CPN25643 Pharmacotherapy Management of COPD Exacerbation HEDIS measure Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Healthcare Effectiveness Data Information Set (HEDIS®) is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). These are used to drive improvement efforts surrounding best practices. The Pharmacotherapy Management of COPD Exacerbation (PCE) measure assesses chronic obstructive pulmonary disease (COPD) exacerbations for adults 40 years of age and older who had appropriate medication therapy to manage an exacerbation. A COPD exacerbation is defined as an acute inpatient discharge or emergency department visit with a primary discharge diagnosis of COPD. Two rates are reported: - Dispensed a systemic corticosteroid (or there is evidence of an active prescription) within 14 days of the event
- Dispensed a bronchodilator (or there is evidence of an active prescription) within 30 days of the event1
COPD is a debilitating lung condition that affects one in eight Americans age 45 and older. More than 16 million Americans have been diagnosed with COPD, and millions more have it without knowing. 2 COPD exacerbations make up a significant portion of the costs associated with the disease. Appropriate prescribing of medication following exacerbation can prevent future flare-ups, improve health outcomes, and reduce the healthcare burden of COPD.3 Who has COPD?4Prevalence by ethnicity | 12% American Indians and Alaska Natives | 7% Non-Hispanic Blacks | 7% Whites | 4% Hispanics | 3% Native Hawaiian/Pacific Islander | 2% Asians |
COPD action plan A COPD action plan is a personalized patient tool that includes the important steps to help manage COPD. It allows patients to track how they are doing and note any concerns to discuss with their provider. It addresses medications, exercise, diet, and avoidance of triggers, such as tobacco products and other inhaled irritants. The plan should be discussed at each visit and updated as needed.5 HEDIS helpful tips:- Schedule a follow-up appointment after discharge and confirm that the patient has the appropriate medications.
- Reconcile patients’ medications with those prescribed at discharge when you receive the discharge summary.
- Ask the patient if they have any barriers that prevent them from filling their prescriptions.
- Assure patients with COPD are up to date on their vaccinations, including flu, pneumococcal, and COVID-19.
- Provide a COPD action plan for the patient, including daily medications, trigger avoidance, and what to do when flare-ups do occur:
Resources: - NCQA. Pharmacotherapy Management of COPD Exacerbation. Pharmacotherapy Management of COPD Exacerbation - NCQA
- National Heart, Lung and Blood Institute. COPD National Action Plan. https://tinyurl.com/4sphb6fy
- Pasquale, M.K., S.X. Sun, F. Song, H.J. Hartnett, and S.A. Stemkowski. Impact of exacerbations on health care cost and resource utilization in chronic obstructive pulmonary disease patients with chronic bronchitis from a predominantly Medicare population. International Journal of COPD 7:757-64. doi: 10.2147/COPD.S36997. https://tinyurl.com/yma3yt7r
- Chronic Obstructive Pulmonary Disease and Smoking Status— United States, 2017, Morbidity and Mortality Weekly Report (MMWR),68(24), pp. 533-538 (June 21, 2019), Centers for Disease Control and Prevention (CDC).
- American Lung Association. COPD Action Plan & Management Tools. American Lung Association COPD Action Plan & Management Tools
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). NYBCBS-CDCRCM-026833-23-CPN26072 |