Pateint360 is a Longitudinal Patient Record (LPR) where you can access the complete view of Empire BlueCross BlueShield (“Empire”) information associated with an Empire member.

You may have noticed that the Care Reminders tab on your Empire patient’s Eligibility and Benefits return on Availity was recently removed. You can still retrieve these important patient gaps in care through Patient360.

You are required to have the Patient360 role assigned to you by your Availity administrator to see the Patient360 tab located at the top of the patient’s Eligibility and Benefits return. To access Patient360 select the tab and follow the steps to open the application.

If your patient does have a gap in care, you will see the red alert button on the top of Patient360 Member Care Summary. Details of the care gap can be found in the Active Alerts section.

Availity Eligibility and Benefits: Patient360 access
 

Patient360 Active Alerts located on the Member Care Summary

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on empireblue.com/

empireblue.com/provider > “Find Resources for New York” > Provider Home > Health & Wellness > Practice Guidelines.

It can be found on empireblue.com/provider > “Find Resources for New York” > Provider Home > Health & Wellness > 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.

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 empireblue.com/provider > Review Policies, View Medical Polices & UM Guidelines.

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:

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 1800 732-8318 (UM), FAX 1-877 606-3807 (ABD) 

To Discuss Peer-to-Peer UM Denials w/Physicians:

Please refer to the phone number on the denial notification letter. 

Pre-service Appeals: 1-800-634-5605 – opt2

FEP: Phone 1-800-860-2156

To Request UM Criteria:

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) 

TDD/TTY:

TTY: 1-800-662-1220

Voice: 800-421-1220

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.

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 including a Coordination of Care Form and Coordination of Care Letter Templates for both Behavioral Health and other Medical Practitioners.* Behavioral Health tools are available, which includes forms, brochures, and screening tools for Substance Abuse, ADHD, and Autism. Please refer to the website for a complete list.**

*Access to the forms and template letters are available at www.anthem.com/provider/forms/

**Access to the Behavioral Health tools are www.anthem.com/provider/forms/

Our recovery process for National Accounts membership is reflected on the Electronic Remittance Advice (835) in the PLB segment. The requested recovered amount on the Electronic Remittance Advice (835) is displayed at the time of the recovery.

As National Accounts membership transitions and claims are adjusted for recovery on the central system, the requested recovered amount will be held for 49 days. This will 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” section.

After 49 days, the requested recovered amount is reflected on the Electronic Remittance Advice (835) in the PLB segment.

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

The coding changes separate test administration from test evaluation, psychological testing from neuropsychological testing, and defined the testing performed by a professional or technician. The new codes were as follows:

Neurobehavioral status exams are clinical interview examinations performed by a psychologist or neuropsychologist to assess thinking, reasoning and judgment. Providers should continue to use CPT code 96116 when billing for the first hour and new code 96121 when billing for each additional hour.

Testing evaluation services include the selection of the appropriate tests to be administered; integration of patient data; interpretation of standardized test results and clinical data; clinical decision-making; treatment planning; and reporting and interactive feedback to the patient, family members, or caregivers, when performed. Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour. Neuropsychological evaluation services should now be billed using CPT code 96132 for the first hour and 96133 for each additional hour.

Test administration and scoring by a psychologist or neuropsychologist (two or more tests using any method) should now be billed using CPT code 96136 for the first 30 minutes and 96137 for each additional 30 minutes.

Test administration and scoring by a technician (two or more tests using any method) should now be billed using CPT code 96138 for the first 30 minutes and 96139 for each additional 30 minutes.

Single automated test administration should be reported with newly created code 96146 for a single automated psychological or neuropsychological instrument that is administered via electronic platform and formulates an automated result. Psychologists should not use this code if two or more electronic tests are administered and/or if administration is performed by the professional or technician. Instead, the psychologist should use the appropriate codes listed above for test administration and scoring.

Screening and risk assessment (repetitive assessment after screening) include brief emotional/behavioral assessment with scoring and documentation, per standardized instrument, should now be billed using CPT code 96127 separately from testing.

References: www.apa.org

Additionally, Empire BlueCross BlueShield (“Empire”) is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements.  For Empire to remain compliant with federal and state requirements, changes must be communicated 30 days in advance of a change or as soon as possible.

Key data elements

The data elements required by CMS and crucial for member access to care are: 

• Physician name
• Location (such as address, suite if appropriate, city/state, zip code)
• Phone number
• Accepting new patient status
• Hospital affiliations
• Medical group affiliations

Empire is also encouraged (and in some cases required by regulatory/accrediting entities) to include accurate information for the following provider data elements:

• Physician gender
• Languages spoken
• Office hours
• Provider specialty/specialties
• Physical disabilities accommodations
• Indian Health Service status
• Licensing information (i.e., medical license number, license state, National Provider Identifier - NPI)
• Email and website address

How to verify and update your information

To verify information, go to empireblue.com/provider > “Provider Resources” select “Find a Doctor” tool.  Use “Search as a Guest” at the bottom.  If your information is not correct, please update the information as soon as possible. 

To update information, go to empireblue.com/provider/ Select “Find Resources in New York”  “Provider Resources” select "Provider Maintenance Form" and follow the online prompts.

For questions about your participation status contact your network relations consultant.

Empire HealthPlus members enrolled under a benefit plan that utilizes the Individual Network will have member ID cards that read cards that read “Individual Network” at the bottom of their member ID card. The prefixes that this plan will be using are VFG or VJD.

If you are included as a provider in the Individual Network, it is important for you to remember that this is an HMO network. The Individual Network will not offer coverage for services received by out of network providers; therefore, please confirm a provider’s participation status with Empire’s Find a Doctor tool found on www.empireblue.com prior to referring to or scheduling services with another provider.

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 www.empireblue.com/provider. Failure to refer patients to a participating provider could result in claim denials and increased out of pocket costs for our members.

Below is a sample copy of the Member’s Card:

Empire members enrolled 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 remember that this is a limited provider network. The products offered under the Blue Access network are PPO, Gatekeeper EPO (GEPO), EPO and HMO. 

The EPO, HMO and GEPO plans will not offer coverage for services received by out of network providers; therefore, please confirm a provider’s participation status with Empire’s Find a Doctor tool found on www.empireblue.com prior to referring to or scheduling services with another provider. 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 www.empireblue.com/provider. Failure to refer patients to a participating provider could result in claim denials and increased out of pocket costs for our members.

Large Group Health Benefit Plans utilizing the Blue Access network:

*PCP and Referrals required

Empire members enrolled under a benefit plan that utilizes the Connection network will have member ID cards that read “Connection” at the top of their member ID card. If you are included as a provider in the Connection network, it is important for you to remember that this is a limited provider network. The product offered under the Connection network is Gatekeeper EPO (GEPO and EPO). 

The EPO and GEPO plans will not offer coverage for services received by out of network providers; therefore, please confirm a provider’s participation status with Empire’s Find a Doctor tool found on www.empireblue.com prior to referring to or scheduling services with another provider

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 www.empireblue.com/provider. Failure to refer patients to a participating provider could result in claim denials and increased out of pocket costs for our members.

The prefixes used for the Connection Network are:

Effective January 1, 2020 new members will not be enrolled in the Blue Priority and Pathway Networks.  Please note there will continue to be membership in the Blue Priority Network throughout 2020. If you are a participating provider in the Blue Priority network, you will still be considered a participating provider and can continue to see our members.

Due to the current ASH Chiropractor utilization management program in New York, Chiropractors will continue to be managed by ASH including requests for review of  certain codes that may  also be part of the AIM Rehab program.  Chiropractors in New York  will not be required to obtain an authorization from AIM.

Also communicated in October, Empire is transitioning vendors for review of Rehabilitative Services for our *Medicare members to include outpatient PT, OT, and ST to AIM Specialty Health.  Empire has decided to delay the implementation of this transition. The AIM Rehab program for Medicare members will now begin in April 2020.  Prior authorization will not be required for the above mentioned services through March 2020.  

*This does not apply to members for whom prior authorization will still be required. Please be sure to check upcoming editions of Provider News for more information about the AIM Rehabilitative Program for Medicare members.

New changes to AIM’s Rehab Program

Empire and AIM Specialty Health are working together to make improvements to the clinical review of PT/OT/ST services when used to treat Autism Spectrum Disorder or Pervasive Developmental Delays as defined by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. 

Empire is working to adjust our claims systems to not look for an authorization for commercial members who are receiving skilled treatment for Autism Spectrum Disorder or Pervasive Developmental Delays with one of the following ICD-10 diagnoses: F84.0, F84.2, F84.3, F84.5, F84.8, or F84.9. Until that time, AIM will continue to issue authorizations for PT, OT, and ST services for those diagnoses to help ensure claims are paid appropriately. We will update you once we confirm the effective date of the removal of the prior authorization configuration in our claim system. Please note that while AIM may issue an authorization, benefit limits, if applicable, will still be applied.

Note: For Empire Medicaid members, there are no changes to the existing program.

Empire BlueCross BlueShield (“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?

Via Email: ECM-NY@Empireblue.com  

Via Phone: 

Empire’s Specialty Pharmacy Level of Care Program launched in July 2016 and was communicated in our April 2016 newsletter.  Empire is expanding the Specialty Pharmacy Level of Care Program, effective March 1, 2020 to include NYC Hospital PPO plan membership.  Specialty Drugs inclusive in the program will be reviewed for both clinical appropriateness and the level of care against health plan clinical criteria (CG-Med-83, CG-DRUG-53) for dates of service beginning March 1, 2020.

Physician offices that currently administer Specialty Drugs in the office setting are not impacted by this change.   We encourage you to discuss with members their level of care options, such as physician office, infusion center or home infusion therapy, as appropriate.

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

• Learn more about the Group Retiree PPO plans
• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ
• CMS reminder: expedited/urgent requests
• Prior authorization requirements for E0784, K0553 and K0554
• Global 3M19 Medical Policy and Technology Assessment Committee prior authorization requirement updates
• 2020 Medicare Advantage individual benefits and formularies

The Medicare Risk Adjustment Regulatory Compliance team at Empire BlueCross BlueShield team developed the following two provider training series titled: 

Medicare risk adjustment and documentation guidance (general)

Series: Offered the first Wednesday of each month from 1 to 2 p.m. Eastern time

Learning objective: Provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.

Credits: This live activity, Medicare Risk Adjustment and Documentation Guidance, offered from December 5, 2018, through December 4, 2019, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians.

Those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process should register for one of the monthly training sessions at the link below:

https://antheminc.adobeconnect.com/admin/show-event-catalog?folder-id=38826374.

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

Series: Offered bimonthly on the fourth Wednesday from noon to 1 p.m. (ET)

Learning Objective: Collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

Credits: This Live series activity, Medicare Risk Adjustment, Documentation and Coding Guidance, from January 23, 2019, to November 27, 2019, has been reviewed and is acceptable for credit by the American Academy of Family Physicians.

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

1. Red flag HCCs, part one — Register for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, end-stage liver disease. Recording will play upon registration. https://antheminc.cosocloud.com/e4i5k4h7cf3j/event/registration.html.
2. Red flag HCCs, part two — Register for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration. https://antheminc.cosocloud.com/enfndbyedd5g/event/event_info.html.
3. Opioids and more: Substance Abuse and Dependence — Recording will play upon registration. https://antheminc.cosocloud.com/ekx3tooh22f7/event/registration.html.
4. Acute, chronic and status conditions — Recording will play upon registration. https://antheminc.cosocloud.com/eeq7am1fht49/event/registration.html.
5. Diabetes Mellitus and Other Metabolic Disorders — Recording will play upon registration. https://antheminc.cosocloud.com/egjswhu5fv73/event/registration.html.
6. Behavioral health — Recording will be available in early December and will play upon registration. https://antheminc.cosocloud.com/p5ss84h25ww/.

EBSCARE-0196-19 October 2019

504964MUPENMUB

Effective January 1, 2020, East End Health Plan retirees who are eligible for Medicare Parts A and B will be enrolled in an Empire MediBlue Freedom (PPO) plan with Empire BlueCross BlueShield (Empire).

The plan includes the National Access Plus benefit, which offers retirees the freedom of receiving services from any provider as long as the provider is eligible to receive payments from Medicare. East End Health Plan retirees will receive both in-network and out-of-network covered services. The Medicare Advantage plan offers the same hospital and medical benefits that original Medicare covers and additional benefits that original Medicare does not, such as an annual routine physical exam, LiveHealth Online and SilverSneakers.

The prefix on East End Health Plan ID cards will be XLU. The cards will also show the East End Health Plan logo and National Access Plus icon.

Claims should not be filed with original Medicare. Providers can submit claims electronically using the electronic payer ID for Empire or submit a UB-04 or CMS-1500 form to Empire.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com.

EBSCRNU-0069-19 October 2019

505495NYPENMUB

Effective January 1, 2020, City of Cincinnati Retirement System to offer  Medicare Advantage Preferred (PPO) (MAPPO), a Medicare Advantage plan from Anthem Blue Cross and Blue Shield. Retirees with Medicare Parts A and B and retirees with only Part B are eligible to enroll in the MAPPO plan. The plan includes the National Access Plus benefit, which allows members to receive  services from any provider as long as the provider is eligible to receive payments from Medicare. The MAPPO plan offers the same hospital and medical benefits that Medicare covers, as well as additional benefits such as an annual routine physical exam, hearing exam, LiveHealth Online and SilverSneakers®.

The prefix on City of Cincinnati Retirement System member ID cards will be ZVR. The cards will also show the City of Cincinnati Retirement System logo and National Access Plus icon.

Providers may submit claims electronically using the electronic payer ID for the Blue Cross Blue Shield plan in their state or submit a UB-04 or CMS-1500 from the Blue Cross Blue Shield plan in their state. Claims should not be filed with Original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about City of Cincinnati Retirement Systems member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com.

EBSCRNU-0073-19 October 2019

505049MUPENMUB

• Stars care gap requests
• HEDIS® requests
• Risk adjustment requests
• Medical record requests

This change in process applies to all Blue plans and will go into effect on January 1, 2020.

The current process

The current process for the above-mentioned requests involves the control/home plan sending requests to providers via Inovalon/vendor for medical records and supplemental data to address and/or close an identified or suspected HEDIS measure, care gap or risk adjustment. Providers receive requests and submit the requested information to the home plan. The home plan receives the information and uses this information, medical records and supplemental data to complete and/or close the request.

The new process

The new process is specific for Medicare Advantage OOA (PPO) members only. These members will be split out from all other members.

For Medicare Advantage OOA members whose home plan is Empire BlueCross (Empire), the Stars care gap, risk adjustment, HEDIS and medical record requests will be processed via the new BCBSA Provider Engagement Data Exchange (PEX) platform. Empire as control/home plan will submit these requests to BCBSA via the PEX system. BCBSA will then route the request to the health plan with which the provider is contracted (host plan). The host plan will initiate the provider engagement and gather the requested information (for example, medical records). Providers contracted by the host plan will submit the requested documentation to the plan. The host plan will then submit the documentation via the PEX system to BCBSA. BCBSA will sort the responses and documentation and send to the requesting home plan (member’s home plan).

When Empire is the host plan, Empire will receive requests for Stars care gap, risk adjustment, HEDIS and medical record requests from the member’s home plan via the PEX system. Empire will process the requests, engage providers, and submit requests for medical records and/or supplemental data to the provider. When the provider supplies a response (medical records, supplemental data or additional requests for information), Empire will send the responses/documentation to the control/home plan via the PEX system. BCBSA will route the responses/documentation to the requesting home plan.

Provider role in new process

Each provider has a key role in the new process. In order to improve the overall care and health outcomes for members, the provider must:

1. Respond to requests for medical records and/or supplemental data in a timely manner.
2. Request additional information from the provider’s contracted plan, if needed, to complete requests.
3. Follow the standard HEDIS, Stars care gap, risk adjustment and medical records requests processes as outlined in the current process.

As a control/home plan, Empire is taking steps to ensure that providers have the resources needed to complete this new process with little or no impact to the provider’s current operations. Additional provider education resources will be communicated as they become available.

For additional information, please refer to the service numbers on the back of the Member ID Card.

EBCCRNU-0066-19 October 2019

505477MUPENMUB

As a reminder, PCPs may only refer Empire BlueCross BlueShield (Empire) members to in-network Medicare Advantage providers.

Empire has contracted with specialists to ensure adequate care of our members. The use of contracted network specialists will ensure continuity of appropriate clinical background data and coordination of care with the PCP.

Should there be a need to refer the member outside the contracted network, contact Empire directly for prior authorization (PA). Referring a Medicare Advantage member out-of-network, who does not have out-of-network benefits, could result in claim denials with member liability unless the service is urgent, emergent, out-of-area dialysis or if PA was approved by the plan.

Although not required, PA is encouraged for preferred provider organization (PPO) members who want to receive notification of advanced coverage when utilizing an out-of-network provider for services.

As a reminder to all providers, the referring physician name and NPI must be reported on the claim when the PCP does not provide the service rendered. This will reduce the number of rejections issued during initial claim processing.

EBSCRNU-0074-19 October 2019

504908MUPENMUB