Empire will introduce a new provider network effective January 1, 2019. This new network is called “Blue Access” and will be a limited network of providers.  Providers who are currently participating in the Pathway network will also be participating in the new Blue Access network.  A letter was sent to all providers who are participating in the Blue Access Network.  For questions about your participation status contact your network management coordinator.  Please note the reimbursement for the Blue Access Network will be  at the current Small Group rate.

 

Empire members that are covered under a benefit plan that utilizes the Blue Access network will have member ID cards that read “Blue Access” at the top of their member ID card. If you are included as a provider in the Blue Access network, it is important for you to understand that this is a limited provider network. Benefit plans offered on the Blue Access network will not cover out of network providers services; therefore, please confirm a provider’s participation status with Empire’s Find a Doctor tool found on empireblue.com prior to referring to or scheduling services with another provider.

 

Only participating Blue Access providers should be used for Empire members that are covered under a benefit plan that uses the Blue Access network. Should a non-participating provider be required, Empire’s Use of a Non-Participating Provider Advance Patient Notice Policy will apply. As a reminder, Empire’s Advance Patient Notice form can be found at empireblue.com. Failure to refer patients to a participating provider could result in increased out of pocket costs for our members.

 

Small Group Health Benefit Plans utilizing the Blue Access network:

 

Product	Network Name	Medical Product Type	Small Group Health Benefit Plans Description	BCA Prefix
Small Group	Blue Access	EPO	Empire Bronze Blue Access EPO Empire Gold Blue Access EPO Empire Platinum Blue Access EPO Empire Silver Blue Access EPO	YXE
Small Group	Blue Access	Gatekeeper EPO	Empire Bronze Blue Access GEPO* Empire Gold Blue Access GEPO* Empire Platinum Blue Access GEPO* Empire Silver Blue Access GEPO*	XNU
Small Group	Blue Access	HSA-HMO	Empire Bronze Blue Access HMO* Empire Gold Healthy New York Blue Access HMO*	YXC YXD

*PCP and Referrals required

There will be a change to Empire’s ACA individual health benefit plans which impacts products sold on and off the New York State of Health Insurance Marketplace (also commonly called the Exchange) effective January 1,2019. 

 

Starting January 1, 2019:

• Members will be required to select a Primary Care Physician (PCP) when enrolling in one of the plans listed below.  You will be able to verify the member’s PCP on Availity (www.availity.com)
• Referrals will be required for all specialist visits. The referral form can be found on www.Empireblue.com-Download Commonly Used Forms and Quick Guides – General Forms
• No Out of Network coverage except in emergency.  Emergent care is covered in and out of network at the member in network cost share. For Out of Area urgent care, only services from a Blue Card provider will be covered.  In network member cost share applies.

 

Individual Health Benefit Plans utilizing the Pathway Network:

 

Network Name	Full Product Name	Prefix	PCP Required	Referral Required	Out-of-Network Benefits
Pathway Enhanced, Gated	Empire Gatekeeper Bronze Empire Gatekeeper Silver Empire Gatekeeper Gold Empire Gatekeeper Platinum Empire Gatekeeper Catastrophic	YAZ	YES	YES	NO
Pathway X Enhanced Gated	Empire Gatekeeper X Bronze Empire Gatekeeper X Silver Empire Gatekeeper X Gold Empire Gatekeeper X Platinum Empire Gatekeeper X Catastrophic	YCZ	YES	YES	NO

 

Empire is targeting January 12, 2019 to retire the Empire Facility and Physician Online Services. All information formerly on the Empire secure portals will be available exclusively through the Availity Portal (www.availity.com). 

 

Your preparations for this transition are vital and should include the following:

• If you are an administrator for your organization's Availity account:  Continue to use My Account Dashboard from the Availity home page to register new users and update or unlock accounts for existing users. Make sure all of your users have the roles they need to ensure a smooth transition.
• If you are a user today who regularly accesses information on both Empire Facility or Physician Online Services and Availity: In these final days before the retirement of the Empire Portals, make sure you are able to access everything you require to perform your job duties of the Availity Portal and work with your administrator to update your access if needed. To determine who your administrator is select My Administrators from your Availity Account Dashboard.
• If your organization is not registered for Availity: Visit https://www.availity.com/ and select REGISTER to get started.  Want more information before starting your registration? Watch this video: Learn how to register your organization with Availity – Training Demo.

 

Finally, users now have two places to obtain valuable training tools and information.  If you would like more information on navigating in Availity, select Help & Training | My Learning Plan from the top navigation menu on the Availity home page to plot your learning journey.  Availity also offers onboarding modules for new administrators and users. To locate these modules select Help & Training | Get Trained to navigate to the Availity Learning Center, then type “onboarding” in the search field.

 

To find presentations and reference guides that can be used to educate you and your staff on Empire proprietary tools, select Payer Spaces| Applications| Education and Reference Center | Education and Communications.

Empire has designated Availity to operate and serve as your electronic data interchange (EDI) entry point (also called the EDI Gateway).  The EDI Gateway is a no-cost option to our direct trading partners.  With this change, Empire continues our efforts to ensure consistency between your provider portal and the EDI Gateway.

 

As a mandatory requirement, all trading partners who currently submit directly to the Empire EDI Gateway must transition to the Availity EDI Gateway.  Availity is well known as a web portal and claims clearinghouse.  In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.

 

Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:

 

• 837- Institutional Claims
• 837- Professional Claims
• 837- Dental Claims
• 835 - Electronic Remittance Advice
• 276/277- Claim Status
• 270/271- Eligibility Request

 

If you wish to become a direct a trading partner with Availity, the setup is easy.

Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Empire EDI transmissions. 

 

If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.

 

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

 

835 Electronic Remittance Advice (ERA)

Effective June 1, 2018, please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

 

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

 

If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.

 

Contacting Availity

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

The Education and Reference Center (ERC) offers the Communication & Education section where you can find training materials, important policy information, commonly used forms and reference guides on Empire’s proprietary tools. When you visit the ERC, you can efficiently navigate to all available electronic resources using only the Availity Portal.

 

The Communication & Education section includes two new categories to help make it easier for you to find what you need:  Payer Spaces and Interactive Care Reviewer. 

 

With an Availity log in you can easily view any new content added to the ERC. There is no additional role assignment needed.  

 

Find the ERC on the Availity Portal under Payer Spaces > Empire> Applications. If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your Favorites.

 

In our company’s ongoing efforts to streamline and simplify our payment recovery process, we continue to consolidate our internal systems and will begin transitioning our National Accounts membership to a central system in 2019. While this is not a new process, we are transitioning the National Accounts membership to align with the payment recovery process across our other lines of business.

 

Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835).  This segment will show the negative balance associated with the member account number.  Monetary amounts are displayed at the time of the recovery adjustment.

 

As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections. 

 

After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments. 

 

If you have any questions or concerns, please contact the E- Solutions Service Desk toll free at (800) 470-9630.

Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) commercial data collection project for 2018. You play a central role in promoting the health of our members. By documenting services in a consistent manner, it iseasier for you to track care that was provided and identify any additional care that is needed to meet the recommended guidelines.  Consistent documentation and responding to our medical record requests in a timely manner eliminates follow up calls to your office and also helps improve HEDIS scores, both by improving care itself and by improving our ability to report validated data regarding the care you provided. The records that you provide to us directly affect the HEDIS results that are listed in the attachment.

Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

 

Empire is available to offer assistance in these difficult moments with our Case Management Program.  Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers.  The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

 

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need.  Physicians can also refer by contacting us telephonically or through electronic means.  No issue is too big or too small.  We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

 

How do you contact us?

 

CM Email Address	CM Telephone Number	CM Business Hours
ECM-NY@Empireblue.com	1-800-563-5909	Monday – Friday 8:30 am – 7:00 pm
National NYCoreANAAtlanta@empireblue.com	1-855-239-0364	Mon - Friday 8am-9pm EST, Saturday 9am-5:30pm EST
Federal Employee Program (FEP) No email	1-800-711-2225	8am-7:00pm EST

Empire members have additional resources available to help them better manage chronic conditions. The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their doctor’s orders and how to become a better self-manager of their condition. 

 

Engagement methods vary by the individual’s risk level but can include:

• Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and resources.
• Round-the-clock phone access to registered nurses.
• Guidance and support from Nurse Care Managers and other health professionals.

 

Physician benefits:

• Save time by answering patients’ general health questions and responding to concerns, freeing up valuable time for the physician and their staff.
• Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and recommendations.
• Inform the physician with updates and reports on the patient’s progress in the program.

 

Please visit the empireblue.com/provider to find more information about the program such as program guidelines, educational materials and other resources.  Also on our website is the Patient Referral Form, which you can use to refer other patients you feel may benefit from our program.

 

If you have any questions or comments about the program, call 1-877-681-6694. Our nurses are available Monday-Friday, 8:00 a.m. to 9:00 p.m., and Saturday, 9:00 a.m. to 5:30 p.m.

An Integrated Care Model affords members with Empire plans purchased on the NY State of Health Marketplace (also called the Exchange) the ability to have continuity of care for certain conditions.  A single Primary Care Nurse provides case and disease assessment and management.  This continuity provides opportunity for the member to get assistance working through an acute phase of an illness and then work with their nurse on the behavioral changes needed to help improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as a supportiveadjunct to physician care.

 

The Integrated Care Model helps Exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease.  Our nurse care managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. 

 

Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan. 

 

Members or caregivers can refer themselves or family members by calling the number located below.  How do you contact Case Management?

• Via phone at 1-800-563-5909, Monday - Friday 8:30 am to 7:00 pm EST
• Via Email at ECM-NY@empireblue.com

Coordination of care among providers is a vital aspect of good treatment planning to help ensure appropriate diagnosis, treatment and referral.  Empire would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

 

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Empire urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins.

 

We expect all health care practitioners to:

 

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

 

In an effort to facilitate coordination of care, Empire has several tools available on empireblue.com/provider including a Coordination of Care template and cover letters for both Behavioral Health and other Healthcare Practitioners.* In addition, there is a Provider Toolkit on the website with information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.**

 

*Access to the forms and cover letters are available at empireblue.com/provider/ > “Find Resources in New York” > Provider Home > Answers@Empire.

 

**Access to the Toolkit is available at empireblue.com/provider/ > “Find Resources in New York” > Provider Home > Health and Wellness.

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

 

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at empireblue.com/provider.

 

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

• Call us toll free from 8:30 a.m. - 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8:00 a.m. – 7 p.m. Eastern.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day.  Calls received after midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

 

The following phone lines are for physicians and their staffs.  Members should call the customer service number on their health plan ID card.

 

To discuss UM Process and Authorizations	To Discuss Peer-to-Peer UM Denials w/Physicians	To Request UM Criteria	TDD/TTY
1-800-982-8089   Transplant 1-800-255-0881   Behavioral Health: 1-800-626-3643   Autism 1-844- 269-0538   FEP Phone 1-800-860-2156 FAX 1-800 732-8318 (UM) FAX 1-877-606-3807 (ABD)	1-800-688-1019 Press 4   1-800-634-5605 Appeals   FEP Phone 1-800-860-2156	Call number on back of member’s ID card   FEP Phone 1-800-860-2156  FAX 1-800-732-8318 (UM) FAX 1-877-606-3807 (ABD)	711 Or   TTY 1-800-662-1220 TTY/HCO Voice 1-800-421-1220 Voice

 

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

 

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.  They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

 

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Empire has adopted a Members’ Rights and Responsibilities statement.

 

It can be found on online at empireblue.com/provider/ Select “Find Resources in New York” >Provider Home > Quality Improvement Standards > Member Rights & Responsibilities.  Practitioners may access the FEP member portal at www.fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

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

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available at empireblue.com/provider/ > “Find Resources in New York” > Provider Home > Health and Wellness > Practice Guidelines.

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

 

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

 

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

 

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

 

Effective January 1, 2019, Medicare providers will have toll free phone numbers specifically designated for their service inquiries. These new provider numbers will be listed separately on the back of the member ID cards and should be used beginning January 1, 2019. The associates answering your provider service calls are trained to answer your questions and resolve your issues as quickly as possible. To ensure you receive the most efficient service, please refrain from using the member services line and use only 844-427-2657 or the provider services phone number listed on the back of the member ID card for provider service for individual Medicare Advantage calls beginning January 1, 2019.

Summary of benefits, evidence of coverage and formularies for 2019 individual Medicare Advantage plans are available at empireblue.com/medicareprovider. An overview of notable 2019 benefit changes also is available at Important Medicare Advantage Updates at empireblue.com/medicareprovider.  Please continue to check Important Medicare Advantage Updates at empireblue.com/medicareprovider for the latest Medicare Advantage information.

The U.S. Centers for Medicare and Medicaid Services (CMS) and Medicare Advantage and Part D organizations, including Empire, will implement a new initiative, the Preclusion List, to protect the integrity of the Medicare Trust Funds. Beginning April 1, 2019, Medicare Advantage and Part D organizations will deny payment for items and services furnished by providers that CMS has placed on the Preclusion List. For more information, visit www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/PreclusionList.html.
,

When a claim must be corrected beyond the initial claim timely filing limit of one year from the date of service, a normal adjustment bill is not allowed. Providers must use the reopening process to correct the error. To learn when and how to initiate reopenings and adjustments, check Important Medicare Advantage Updates at empireblue.com/medicareprovider. 

Beginning January 1, 2019, Individual Medicare Advantage plans will move compounded drugs to non-formulary with the exception of home infusion drugs. Group-sponsored Medicare Advantage members will continue to have compounded drug coverage; these drugs will require prior authorization. Compounded home infusion drugs will continue to be covered for both Individual Medicare and group-sponsored members without prior authorizations. Members and/or providers can request a non-formulary exception for compounded drugs. 

CMS updated its guidance to allow Medicare Advantage plans the option of implementing step therapy for Part B drugs as part of a patient-centered care coordination program beginning January 1, 2019.  The goal is to lower drug prices while maintaining access to covered services and drugs for beneficiaries. Empire will implement step therapy edits to promote clinically appropriate and cost effective drug options for our members. A patient-centered care coordination program will be created to ensure member access to necessary drugs, provide medication reviews and reconciliations, educate members regarding their medications, encourage medication adherence, and provide incentives to members who complete care coordination programs.

We are pleased to announce the expansion of our MediBlueSM Select HMO provider network beginning January 1, 2019.  This network will support a specific line of Medicare Advantage products and programs focused on quality metrics and improvements. MediBlue Select HMO members will have Empire MediBlue Select (HMO) in the upper right-hand corner of their member ID cards. 

 

Participating primary care physicians (PCPs) and specialists in this network have received a notice in the mail of inclusion in the MediBlue Select HMO network.  All MediBlue participating hospitals, ancillary providers and ancillary facilities are included in this network.

 

All provider questions may be directed to the Provider Call Center at 800 499-9554.

 

Patients may come to you with questions about the Empire Select HMO plan.  To assist, we have set up a toll free number 1-888-598-5614 to help answer questions and enroll the patient to the new Empire Select HMO.

74188MUPENMUB 09/14/2018

The Medical Policy and Technology Assessment Committee (MPTAC) recently approved a number of Medical Policies. Details are available at Important Medicare Advantage Updates at empireblue.com/medicareprovider

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

Medicare Advantage information, including:

• Prior authorization requirements for Colonoscopy and Upper Gastrointestinal Endoscopy  
• 2019 benefit update summary
• Medicare Advantage Reimbursement Policy October Provider Bulletin  
• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila  
• July Medicare Advantage reimbursement policy  
• Submit PA medication requests electronically; new phone number for MA prescription PAs 
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  
• Inpatient Readmissions  
• Group sponsored Medicare Advantage plan members to receive new ID cards  

 

74837MUPENMUB 10/25/2018

Empire BlueCross BlueShield HealthPlus has designated Availity as a no-cost option to operate and service your electronic data interchange (EDI) entry point (or EDI gateway). This designation will ensure greater consistency and efficiency in EDI submission.

 

Who is Availity?

Availity is well known as a web portal and claims clearinghouse, but they are much more. Availity also functions as an EDI gateway for multiple payers and serves as the single EDI connection.

 

Your organization can submit and receive the following transactions through Availity’s EDI gateway:

• 837 — institutional claims
• 837 — professional claims
• 837 — dental claims
• 835 — electronic remittance advice (ERA)
• 276/277 — claim status
• 270/271 — eligibility request

 

Get started with Availity:

• If you wish to submit directly to Availity, setup is easy. Go to the Availity Welcome Application and begin the process of connecting to the Availity EDI Gateway for your EDI transmissions.
• If you wish to use a clearinghouse or billing company, please work with them to ensure connectivity.

 

Need assistance?

The Availity Quick Start Guide will assist you with any EDI connection questions.

 

Availity payer IDs

You can access the Availity Payer List here.

 

Electronic funds transfer (EFT) registration

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at a time.

 

If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes.

 

ERA registration

Use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Manage your paper remittance vouchers suppression (turn off) here.

 

Contacting Availity

If you have any questions, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548) Monday through Friday from 8 a.m. to 7:30 p.m. Eastern time.

Starting November 5, 2018, Empire uses MCG Care Guidelines for authorization review of inpatient and outpatient mental health services. We will continue to use LOCADTR for the review of substance-use treatment.

 

Providers should continue to use the phone number indicated on the back of the member ID card for notifications and to request authorization review for these services. Additionally, providers may initiate notifications and requests online at https://www.availity.com.

 

For questions, please call Provider Services at 1-800-450-8753.

Effective February 1, 2019, prior authorization (PA) requirements will change for the infusible/injectable drug Sublocade to be covered by Empire HealthPlus. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

• Sublocade (Buprenorphine) — implant (J0570)
• Sublocade — injectable (Q9991, Q9992)

 

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-450-8753 for PA requirements.

Effective February 1, 2019, prior authorization (PA) requirements will change for the Subcutaneous Implantable Defibrillator system to be covered by Empire HealthPlus. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

• Subcutaneous Implantable Defibrillator system — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation (33270)

 

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-450-8753 for PA requirements.

In the last edition of the Network Update, Empire HealthPlus communicated that the prior authorization for high-level, definitive drug testing(s) was changing for Medicaid Managed Care members.

 

There is a delay in implementing this change and a new effective date has yet to be determined.

 

If you have questions about this communication, please contact your Provider Relations representative.

Viral suppression is a key component to New York State’s Ending the Epidemic initiative. The initiative launched in 2014 with the goal of reducing the number of new HIV infections to just 750 per year (from an estimated 3,000) by 2020 and achieving the first ever decrease in HIV prevalence in New York.

 

The three-point plan includes:

1. Identifying persons with HIV who remain undiagnosed and linking them to health care.
2. Linking and retaining persons diagnosed with HIV in health care to maximize viral suppression so they remain healthy and prevent further transmission.
3. Facilitating access to pre-exposure prophylaxis (PrEP) for high-risk persons to keep them HIV negative.

 

The Annals of Internal Medicine recently published a study using data on over 31,900 people living with HIV (PLWH). At the end of the study period, 47% of patients were still alive and receiving care. The findings were that rates of HIV viral suppression among PLWH significantly increased from 1997 to 2015. Factors contributing to better viral suppression rates included:

• Use of integrase inhibitors.
• Improved availability of HIV treatment.
• High rates of PLWH on treatment.

 

Dr. Heidi M. Crane of the University of Washington in Seattle stated, “Viral-suppression rates are rapidly improving among patients with HIV who are in clinical care; however, disparities still exist.” Rates of viral load suppression are lower for blacks (especially men that have sex with men), younger patients and injection-drug users. It is important to connect all patients living with HIV to high quality care, but more intervention may be needed for certain patients to reach the goal of viral suppression. Connecting patients to community programs focused on treatment adherence and other needs such as food and housing can make all the difference.

 

In New York State, there are Retention and Adherence programs with the sole purpose of facilitating access to treatment, engaging with patients who are not virally suppressed and enhancing partnerships with providers and those who are not retained in care to help improve health outcomes. We, as a health plan, also offer case management services to our members.

 

Empire HealthPlus offers case management programs for those infected with who are having difficulty accessing services or remaining in care. To refer a member to our case management program or to find out about a Retention and Adherence program within New York State, please contact Cristobal Garcia at cristobal.garcia@empireblue.com.

Professional providers and facilities are required to submit additional documentation for adjudication of applicable types of claims. If the required documentation is not submitted, the claim may be denied. Empire BlueCross BlueShield HealthPlus may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations.

 

Effective March 1, 2019, if an itemized bill is requested and/or required, then it must include the appropriate revenue code for each individual charge.

 

For additional information, please review the Claims Requiring Additional Documentation reimbursement policy at www.empireblue.com/nymedicaiddoc

Effective January 1, 2019, Empire HealthPlus will transition its Outpatient Rehabilitation Utilization Management (UM) Program from OrthoNet to Empire (pending New York State Department of Health approval). The Outpatient Rehabilitation UM Program is a pre‑service medical necessity review of physical, occupational and speech therapy services.

 

Empire will continue to use criteria documented in Empire’s clinical guidelines GC.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://www.availity.com. Log into Availity, select Payer Spaces, Education and Reference Center application, Clinical Resources and then choose Empire Medical Policy and Clinical UM Guidelines.

 

Pre-service review requirements

For services that are scheduled to be rendered through December 31, 2018, physicians must contact OrthoNet to obtain all prior authorizations for outpatient rehabilitation services. Any authorizations OrthoNet makes prior to the transition date of December 31, 2018, will be honored and claims will process accordingly.

 

For services that are scheduled to be rendered on or after January 1, 2019, physicians must contact Empire to obtain prior authorization for outpatient rehabilitation services. Empire will begin accepting these authorization requests on December 17, 2018. Providers are strongly encouraged to verify that a prior authorization has been obtained before scheduling and performing services.

 

This program will continue to render prior authorization reviews of rehabilitative and habilitative outpatient and office physical, occupational and speech therapy services for medical necessity. Therapy services to be rendered after the initial evaluation will be reviewed against Empire. Clinical guidelines services rendered in an inpatient, emergency, observation or home setting will continue to be excluded from this review. In addition, services rendered by a chiropractor, massage therapist, acupuncturist and home health agency will continue to be excluded from this review.

 

Detailed prior authorization requirements are available online by accessing the Precertification Look-Up Tool under Payer Spaces at https://www.availity.com. Contracted and noncontracted providers may call our Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed.

 

How to place a review request

Authorizations will be accepted for outpatient rehabilitation services on December 17, 2018. 

• Providers can fax requests to Empire at 1-844-815-4708.
• Provider can also call 1-212-563-5570 at extension 1062001261 prompt 1or toll free at 1-800-450-8753

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Note:

• Effective November 1, 2018, AIM Specialty Healthâ (AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Advanced Imaging Guidelines will be used for clinical reviews.
• When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.

 

Please share this notice with other members of your practice and office staff.

 

To search for specific policies or guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.

 

Medical Policies

On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).

 

Publish date	Medical Policy number	Medical Policy title	New or revised
8/29/2018	DRUG.00096	Ibalizumab-uiyk (Trogarzo™)	New
8/29/2018	GENE.00049	Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)	New
8/29/2018	ADMIN.00007	Immunizations	Revised
8/29/2018	DRUG.00046	Ipilimumab (Yervoy®)	Revised
8/29/2018	DRUG.00050	Eculizumab (Soliris®)	Revised
8/2/2018	DRUG.00067	Ramucirumab (Cyramza®)	Revised
8/2/2018	DRUG.00071	Pembrolizumab (Keytruda®)	Revised
8/29/2018	DRUG.00075	Nivolumab (Opdivo®)	Revised
8/29/2018	DRUG.00088	Atezolizumab (Tecentriq®)	Revised
8/29/2018	DRUG.00098	Lutetium Lu 177 dotatate (Lutathera®)	Revised
8/29/2018	GENE.00006	Epidermal Growth Factor Receptor (EGFR) Testing	Revised
8/2/2018	GENE.00011	Gene Expression Profiling for Managing Breast Cancer Treatment	Revised
8/29/2018	GENE.00025	Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors	Revised
8/29/2018	GENE.00029	Genetic Testing for Breast and/or Ovarian Cancer Syndrome	Revised
8/2/2018	MED.00124	Tisagenlecleucel (Kymriah®)	Revised
8/2/2018	SURG.00023	Breast Procedures including Reconstructive Surgery, Implants and Other Breast Procedures	Revised
8/2/2018	SURG.00032	Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention	Revised

 

Clinical UM Guidelines

On July 26, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or Revised
9/20/2018	CG-DME-45	Ultrasound Bone Growth Stimulation	New
9/20/2018	CG-DRUG-103	Botulinum Toxin	New
9/20/2018	CG-DRUG-104	Omalizumab (Xolair®)	New
9/20/2018	CG-DRUG-105	Abatacept (Orencia®)	New
9/20/2018	CG-DRUG-106	Brentuximab Vedotin (Adcetris®)	New
9/20/2018	CG-DRUG-107	Pharmacotherapy for Hereditary Angioedema	New
9/20/2018	CG-DRUG-108	Enteral Carbidopa and Levodopa Intestinal Gel Suspension	New
9/20/2018	CG-DRUG-109	Asfotase Alfa (Strensiq™)	New
9/20/2018	CG-DRUG-110	Naltrexone Implantable Pellets	New
9/20/2018	CG-DRUG-111	Sebelipase alfa (KANUMA™)	New
9/20/2018	CG-DRUG-112	Abaloparatide (Tymlos™) Injection	New
9/20/2018	CG-MED-73	Hyperbaric Oxygen Therapy (Systemic/Topical)	New
9/20/2018	CG-MED-74	Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry	New
9/20/2018	CG-MED-75	Medical and Other Non-Behavioral Health-Related Treatments for Autism Spectrum Disorders and Rett Syndrome	New
9/20/2018	CG-MED-76	Magnetic Source Imaging and Magnetoencephalography	New
9/20/2018	CG-MED-77	SPECT/CT Fusion Imaging	New
9/20/2018	CG-REHAB-11	Cognitive Rehabilitation	New
9/20/2018	CG-SURG-81	Cochlear Implants and Auditory Brainstem Implants	New
9/20/2018	CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids	New
10/31/2018	CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity	New
9/20/2018	CG-SURG-84	Mandibular/Maxillary (Orthognathic) Surgery	New
10/31/2018	CG-SURG-85	Hip Resurfacing	New
10/31/2018	CG-SURG-86	Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection	New
9/20/2018	CG-SURG-87	Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring Previous title: Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring	New
9/20/2018	CG-SURG-88	Mastectomy for Gynecomastia	New
9/20/2018	CG-SURG-89	Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia	New
8/29/2018	CG-ADMIN-02	Clinically Equivalent Cost Effective Services — Targeted Immune Modulators	Revised
8/29/2018	CG-DRUG-09	Immune Globulin (Ig) Therapy	Revised
8/29/2018	CG-DRUG-65	Tumor Necrosis Factor Antagonists	Revised
8/29/2018	CG-DRUG-68	Bevacizumab (Avastin®) for Non-Ophthalmologic Indications	Revised
8/29/2018	CG-DRUG-73	Denosumab (Prolia®, Xgeva®)	Revised
8/29/2018	CG-DRUG-81	Tocilizumab (Actemra®)	Revised
8/29/2018	CG-GENE-03	BRAF Mutation Analysis	Revised
8/29/2018	CG-MED-35	Retinal Telescreening Systems	Revised
8/29/2018	CG-MED-71	Wound Care in the Home Setting	Revised
8/2/2018	CG-SURG-24	Functional Endoscopic Sinus Surgery (FESS)	Revised
8/29/2018	CG-SURG-49	Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities	Revised
8/2/2018	CG-SURG-73	Balloon Sinus Ostial Dilation	Revised

 

Substance use disorders can affect a person’s brain and in turn their behavior. Substance use can start with the experimental use of a drug in a social situation or exposure to prescribed medications. Eventually it can lead to an inability to control the use of the legal or illegal drug or medication. When a patient is diagnosed with an alcohol- or drug- use disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations and comorbidities. This article will provide you with the information you need to provide high-quality care to patients struggling with substance use as well as how to code for the services provided to them.

 

Drug and substance addiction in the U.S.

The U.S. Department of Health and Human Services declared a public health emergency in 2017 due to an unprecedented opioid epidemic. Drug overdose deaths and opioid-involved deaths continue to increase in the U.S.1

 

Smoking is the leading preventable cause of death in the United States. According to the Centers for Disease Control (CDC), 15.5 % of all adults (37.8 million people) were current cigarette smokers in 2016.2

 

Health risks of drug use and smoking

Drugs can have significant and damaging short-term and long-term effects, including psychotic behavior, seizures or death due to overdose. Dependence on drugs can create a number of dangerous and damaging complications, such as accidents, suicide, family/work/school problems and legal issues.

 

Smoking diminishes overall health and is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease (COPD) and many other diseases. There are also health dangers of involuntary exposure to (second-hand) tobacco smoke. Smoking increases risks for preterm delivery.3

 

Diagnosis and treatment

Diagnosing substance use disorders requires a thorough evaluation and includes an assessment by a psychiatrist or a psychologist or an independently licensed behavioral health practitioner that has met the state requirements to render a diagnosis. Blood, urine or other lab tests are used to assess drug use.

 

People with behavioral disorders are more likely to experience a substance use disorder and people with a substance use disorder are more likely to have behavioral health issues when compared to the general population. According to the National Survey of Substance Abuse Treatment Services, about 45% of Americans seeking treatment of substance use/abuse have also been diagnosed with behavioral health problems.4

 

When diagnosing a substance use disorder, most mental health professionals use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

 

Treatment depends on the type of substance used and any related medical or behavioral health disorders that the patient may have. Some treatment options include:

• Chemical dependence treatment programs
• Detoxification
• Behavioral therapy
• Self-help groups

 

There are a lot of treatments to support tobacco cessation, including behavioral therapies and FDA-approved medications. Some treatment options to help ensure tobacco cessation include:

• Nicotine replacement therapy (NRT), as well as bupropion and varenicline
• Combination of behavioral treatment and cessation medications
• Mobile devices and social media help to boost tobacco cessation
• Tobacco cessations are not recommended for adolescents due to lacking high-quality studies
• Behavioral counseling can be provided either in person or by telephone and a variety of approaches are available such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), telephone support lines, text messaging, web-based services and social media.5

 

HEDIS® quality measures

Initiation and Engagement of Alcohol and Other Drug Abuse Dependence Treatment (IET) is a measure that assesses the percentage of plan members’ ages 13 years and older with the new episode of alcohol or other drug (AOD) abuse or dependence who received the following: initiation of AOD and engagement of AOD.

 

Initiation of treatment is the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.

 

Engagement of treatment is the percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days after the initiation visit.6 This measure now includes medication-assisted treatment (MAT) as an appropriate treatment for people with alcohol and opioid dependence. This measure also adds telehealth to treatment options.

 

Use of Opioids at High Dosage (UOD) is a first year quality measure that assesses the number of members 18 years and older per 1,000 beneficiaries receiving prescription opioids for ≥ 15 days during the measurement year at a high dosage (average morphine equivalent dose > 120 mg).7

 

Use of Opioids from Multiple Providers (UOP) is a first year quality measure that assesses the number of members 18 years and older per 1,000 receiving a prescription for opioids for ≥ 15 days during the measurement year who received opioids from multiple providers. Three rates are reported:

• Multiple prescribers – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers during the measurement year
• Multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
• Multiple prescribers and multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.7

 

Unhealthy Alcohol Use Screening and Follow-Up (ASF) is a measure that assess the percentage of health plan members 18 years and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care.

• Unhealthy alcohol use screening – the percentage of members who had a systematic screening for unhealthy alcohol use
• Counseling or other follow-up – the percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening.

 

The intent of the measure: alcohol misuse is a leading cause of illness, lost productivity and preventable death in the U.S.7

 

Medical Assistance with Smoking and Tobacco Use Cessation (MSC) is a survey measure that assesses different facets of providing medical assistance with smoking and tobacco use cessation. There are three components of the survey:

• Advising Smokers and Tobacco Users to Quit: Adults 18 years of age and older who are current smokers or tobacco users and who received cessation advice during the measurement year
• Discussing Cessation Medications: Adults 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year
• Discussing Cessation Strategies: Adults 18 years of age and older who are current smokers or tobacco users who discussed or were provided cessation methods or strategies during the measurement year.

 

ICD-10-CM: general coding information

When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations, and comorbidities.

 

Details are required from the documentation to identify use, abuse or dependence of the substance.

Based on ICD-10-CM Coding Guidelines, when use, abuse or dependence of the same substance are documented in the medical record, only one code should be assigned based on the following hierarchy:

• If both use and abuse are documented, the code for abuse should be assigned
• If both abuse and dependence are documented, the code for dependence should be assigned

• If use, abuse and dependence are documented, the code for dependence should be assigned
• If both use and dependence are documented, the code for dependence should be assigned.8

 

Alcohol dependence and abuse

• Alcohol related disorders are classified to category F10-. An additional code for blood alcohol level (Y90.-) may be assigned, if applicable

• Alcohol abuse is classified under subcategory F10.-, Alcohol abuse

• Alcohol dependence is classified under subcategory F10.2-, Alcohol dependence
• Both categories alcohol abuse and alcohol dependence, are further subdivided to specify the presence of intoxication or intoxication delirium. Additional characters are also provided to specify alcohol-induced mood disorder, psychotic disorder, and other alcohol-induced disorders

• Codes in sub classification F10.23-, Alcohol dependence with withdrawal, provide additional detail regarding withdrawal symptoms such as delirium and perceptual disturbance

• Selection of codes “in remission” for categories F10-F19 requires the provider’s clinical judgement. The appropriate codes for “in remission” are assigned only on the basis of provider documentation, unless otherwise instructed by the classification
• Toxic effect of alcohol is not classified to category F10 but to subcategory T51.0- instead.9

 

Drug dependence and abuse

ICD-10-CM classifies drug dependence and abuse in the following categories according to the class of the drug:

 

F12	Cannabis related disorders
F13	Sedative, hypnotic or anxiolytic related disorders
F14	Cocaine related disorders
F15	Other stimulant related disorders
F16	Hallucinogen related disorders
F17	Nicotine dependence
F18	Inhalant related disorders
F19	Other psychoactive substance related disorders

 

• In most cases, fourth characters indicate whether the disorder is nondependent abuse (1), dependence (2), or unspecified use (9).
• Additional characters also provided to specify intoxication, intoxication delirium, and intoxication with perceptual disturbance.
• Patients with substance abuse or dependence often have related physical complications or psychotic symptoms. These complications are classified to the specific drug abuse or dependence, with the fifth or sixth characters providing further specificity regarding any associated drug-induced mood disorder, psychotic disorder, withdrawal, and other drug-induced disorders (such as sleep disorder).

 

Tobacco use and dependence

Category F17. - (nicotine dependence) codes are located in chapter 5 of the ICD-10-CM book.

 

The Excludes 1 note reminds that this is not the same diagnosis as tobacco use (Z72.0) nor the history of tobacco dependence (Z87.891). Therefore, the documentation will need to specifically discern between tobacco use and nicotine dependence.

 

The Excludes 2 note reminds to code tobacco use (smoking) during pregnancy, childbirth and the puerperium (O99.33-) and toxic effect of nicotine (T65.2-).

 

If the patient has been in contact with, or in close proximity to, a source of tobacco smoke, then Z77.22, Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic), need to be reported.

 

Tobacco abuse counseling is reported using code Z71.6 with the additional code for nicotine dependence (F17.-).

 

ICD-10-CM classifies nicotine dependence by substance:

• F17.20-, nicotine dependence, unspecified
• F17.21-, nicotine dependence, cigarettes
• F17.22-, nicotine dependence, chewing tobacco
• F17.29-, nicotine dependence, other tobacco product.9

 

Each category further breaks down the dependence using a sixth character to denote:

0	Uncomplicated
1	In remission
3	With withdrawal
8	With other nicotine-induced disorders

 

References:

1. Opioid overdose. Overview of an epidemic. https://www.cdc.gov/drugoverdose/data/index.htm
2. Current cigarette smoking among adults – United States, 2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6702a1.htm?s_cid=mm6702a1_w%20
3. CDC. Health effects of cigarette smoking. Retrieved on 1/18/2018 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
4. Treatment for co-occurring mental and substance use disorders. https://www.samhsa.gov/treatment
5. What are treatments for tobacco dependence? Retrieved on 1/18/2018 from https://www.drugabuse.gov/publications/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence
6. HEDIS Benchmarks and Coding Guidelines for Quality Care. Amerigroup RealSolutions in healthcare. Retrieved from https://providers.amerigroup.com
7. NCQA updates quality measures for HEDIS 2018. http://www.ncqa.org/newsroom/details/ncqa-updates-quality-measures-for-hedisreg-2018?ArtMID=11280&ArticleID=85&tabid=2659
8. ICD-10-CM Expert for Physicians. The complete official code set (2017). Optum 360
9. Leon-Chisen N. (2017). ICD-10-CM and ICD-10-PCS Coding Handbook 2018. American Hospital Association, Chicago, IL.

 

These links lead to third-party sites. These organizations are solely responsible for the content on their sites.

 

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

Need up-to-date pharmacy information?

Log in to our provider website (www.empireblue.com/nymedicaiddoc) to access our Formulary, Prior Authorization form, Preferred Drug List and process information.

 

Have questions about the Formulary or need a paper copy?

Call Provider Services at 1-800-450-8753.

 

Our Member Services representatives serve as advocates for our members. To reach Member Services, please call 1-800-300-8181 (TTY 711).

The credentialing process must be completed before a practitioner begins seeing members and enters into a contractual relationship with a health care insurer. As part of our credentialing process, practitioners have certain rights as briefly outlined below.

 

Practitioners can request to:

• Review information submitted to support their credentialing application.
• Correct erroneous information regarding a credentialing application.
• Be notified of the status of credentialing or recredentialing applications.

 

The Council for Affordable Quality Healthcare (CAQH®*) universal credentialing process is used for all providers who contract with Empire BlueCross BlueShield HealthPlus (Empire). To apply for credentialing with Empire, go to the CAQH website at https://www.caqh.org and select CAQH ProView™. There is no application fee.

 

We encourage practitioners to begin the credentialing process as soon as possible when new physicians join a practice. Doing so will help minimize any disruptions to the practice and members’ claims.

 

* CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).