 Provider News New YorkDecember 2020 Empire Provider NewsBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 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 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?
- CM Email Address: nationalpriorityrefe@ChooseHMC.com
- CM Telephone Number: 1-855-239-0364, 1-800-255-0881 (Transplant)
- CM Business Hours: Mon - Friday 8am-9pm EST, Saturday 9am-5:30pm EST, Mon-Friday 8:30am-5pm EST (Transplant)
- FEP Telephone Number: 1-800-711-2225
- FEP Business Hours: 8am-7:00pm EST
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Anthem Inc. and Quest Diagnostics have entered into a strategic relationship by collaborating on a variety of outcomes-based programs designed to create an improved health care experience for consumers and providers beginning August 1, 2020.
Anthem and Quest will work together to improve efficiency in care delivery and reduce overall costs by leveraging a broad range of tools and programs to drive operational improvements, create pricing transparency, and enhance health care consumer engagement and outcomes. The strategic relationship will focus on consumers in California, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, New York, Ohio, Virginia, and Wisconsin.
Please note that the joint press release may be accessed at https://newsroom.questdiagnostics.com/2020-08-17-Anthem-and-Quest-Diagnostics-Form-Strategic-Relationship.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Provider Digital Engagement Supplement is another example of how Empire BlueCross BlueShield (“Empire”) is using digital technology to improve the health care experience. The Supplement outlines Empire provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits all in one comprehensive resource. We want providers to go digital with Empire no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.
Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:
- File claims
- Check statuses
- Verify eligibility and benefits
- Submit prior authorizations
Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit Anthem.com and use the Log In button for access to our secure provider portal, or via the Availity EDI website.
Get payments faster
- Electronic Funds Transfer (EFT) eliminate the need for paper checks. Payments are deposited directly to your bank account. It is safe, secure and you receive payments faster.
Eliminate paper remittances
- Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.
Member IDs go digital
Having an ID card emailed directly to you from the member for file upload eliminates the need for you to scan or print, making it easier for you and the member. Member ID cards can also be accessed from the Availity. Save time by accepting the digital member ID cards when presented by the member via their App or email.
Read more about going digital with Empire in the Provider Digital Engagement Supplement available online. Go to empireblue.com/providers, under the Provider Resources heading select Forms and Guides. From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Through predictive analytics, health care teams can now receive real-time solutions to claim denials
Empire BlueCross BlueShield (“Empire”) is committed to providing digital first solutions. Our health care teams can now use self-service tools to reduce the amount of time spent following up on claim denials.
Through the application of predictive analytics, Empire has the answers before you ask the questions. With an initial focus on claim-level insights, Empire has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to completion. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOB.
Access Claims Status Listing on Payer Space from our secure provider portal through empireblue.com by using the Log In button on through the Availity Portal. We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.
Claim resolution daily
Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.
Empire has made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online – all in one place.
Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Empire is using digital technology to improve the health care experience.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. New health plans built around Empire BlueCross BlueShield (“Empire”) Blue High-Performance Network will take effect Jan. 1, 2021.
Blue HPN® plans offer access to providers with a record of delivering high-quality, efficient care. Blue HPN networks will go live January 1, 2021 in more than 50 cities across the country.
Blue HPN is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue HPN.
In New York, Empire is offering large and small group employers plans with access to the Blue HPN, with the existing Connection network as the New York HPN entry.
Beginning January 1, you may see patients accessing the Blue HPN/Connection network through new products. These will be EPO plans or HSA plans with an EPO network. Under these plans, out of network benefits are limited to emergency or urgent care.
If you are not sure whether your practice is part of the Blue HPN/Connection Network, ask your office manager or business office, or contact your Empire Provider Relations Representative. Blue HPN participation will be displayed in provider profiles in our online provider directory January 1, 2021.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Starting January 1 st, 2021, Building Service 32BJ Health Fund Members will begin using a new 9-digit health care identification numbers (HCID). The new 9-digit member ID number begins with the letter “BJ” + (7) numeral digits (e.g. BJ1234567).
New Empire BlueCross BlueShield (“Empire”) HCID numbers will be required for all Building Service 32BJ Health Fund members claims and inquiries. Provider transactions that are submit using the prior 11- digit member HCIDs to Empire’s systems of engagement (web and EDI) portals will not be recognized.
The new Empire ID cards for Building Service 32BJ Health Fund members with the new 9-digit HCID should not be used prior to January 1st, 2021.
9-digit HCIDs will be on Empire ID Cards
ATTACHMENTS (available on web): 32BJ ID Card.png (png - 0.07mb) Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) is committed to reducing cost while improving health outcomes. To that end, effective March 1, 2021 Empire will require prior authorization for our commercial business
for the following services:
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E0766
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Electrical stimulation device used for cancer treatment, includes all accessories, any type
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53447
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Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session
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53445
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Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff
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C1767
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Generator, neurostimulator (implantable), non-rechargeable
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36465
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Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein)
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36466
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Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg
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33477
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Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed
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Providers can submit pre-service review requests using one of the following ways:
- Availity Portal at https://www.availity.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Call toll-free number at 1-800-982-8089, Monday through Friday 8:30 a.m. to 5:00 p.m. ET.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form, on empireblue.com/provider.
The impact of COVID-19 in 2020 prohibited Empire BlueCross BlueShield (“Empire”) from conducting the annual after-hours access studies to assess phone messaging for our members for perceived emergency or urgent situations after regular office hours. We will resume the survey in the second quarter of 2021 and expect when your office is contacted, you will be able to accommodate a member’s urgent concerns after hours.
To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, such as:
Emergency situations
The compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the doctor.
Urgent situations
The compliant response for urgent needs would direct the caller to Urgent Care or ER, to call 911 or connect the caller to their doctor or the doctor on call.
Messaging that only gives callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions is not complaint, as there is no direct connection to their health care practitioner. This prompt can be used in addition to, but not in place of the emergency and urgent instructions.
Is your practice compliant?
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As of December 1, 2020, the providers listed below are participating air ambulance providers with Empire BlueCross BlueShield (“Empire”). That means, for members picked up in New York, these participating providers have contractually agreed to accept the Empire rate as payment in full for approved and medically necessary transport and will bill those members for cost-shares only.
Some air ambulance providers choose not to participate with Empire.
- These air ambulance providers may, and often do, charge members rates that are significantly higher than the Empire contracted provider rates.
- These non-contracted air ambulance providers, attempt to collect from Empire members the difference between Empire’s allowed amount and their costly billed amount.
To help Empire members avoid the high costs of air transportation from non-contracted providers, we ask that, whenever possible, you choose a participating air ambulance provider for your patients who are Empire members.
Utilizing participating providers:
- Protects the member from balance billing for what may be excessive amounts,
- Assures the most economical use of the member’s benefits, and
- Is consistent with your contractual obligations to refer to in-network providers where available.
To schedule fixed wing or rotary wing air ambulance services, please
- Contact Empire for precertification for all non-emergent transports, using the number on the back of the member’s ID card, then
- Call one of the phone numbers listed below.
Please have the following information ready when you call one of the contracted air ambulance providers
- Basic medical information about the patient, including the patient’s name and date of birth or age. If the service was not precertified with Empire, the air ambulance provider will also need to receive a full medical report from the attending facility.
- Current location of the patient, the name of the hospital or facility caring for the patient and its address (city and state).
- Location where patient is to be transported, including the name of the destination hospital/facility and address.
- Approximate transport date or timeframe.
- Special equipment or care needs.
Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of New York please contact your Provider Network Manager
First, call Empire for precertification if required by the member’s policy. Then call one of the following:
Fixed Wing (Airplane) Providers (HCPCS CODES: A0430 & A0435)
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Provider Name
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Phone#
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Location Address
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Web site
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AeroCare Medical Transport Systems
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630-466-0800
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43W 752 Hwy 30 Sugar Gove IL 60554
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www.aerocare.com
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Air Med International
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877-288-5340
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950 22nd St. Ste 800
Birmingham AL 35203
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www.airmed.com
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Center for Emergency Medicine of Western PA DBA Stat MedEvac
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416-460-3000
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10 Alleghany County Airport, West Mifflin, PA 15122
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www.upmc.edu
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Rotary Wing (Helicopter) Providers (HCPCS CODES: A0431 & A0436)
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Provider Name
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Phone#
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Location Address
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Web site
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Air Methods (Rocky Mountain/LifeNet
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909-915-2305
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7211 South Peoria, Englewood, CO 80112-4133
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www.airmethods.com
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Center for Emergency Medicine of Western PA DBA Stat MedEvac
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416-460-3000
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10 Alleghany County Airport, West Mifflin, PA 15122
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www.upmc.edu
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Med Trans Corp
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888-807-9189
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220 Westcourt Rd.
Denton TX 76207
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www.med-trans.net
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To arrange air transport originating outside of the U.S., U.S. Virgin Island and Puerto Rico, call 1-800-810-BLUE for BCBS for Global Core formerly BlueCard Worldwide.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Are you looking for creative ways to talk to your patients about certain preventive care services such as breast cancer screening and adolescent vaccinations including the HPV vaccination? As flu season approaches, do you want a way to educate your patients about the dangers of antibiotic resistance? S
Short educational videos, approximately two minutes in length, are available on empireblue.com/provider > Forms and Guides > Choose “Patient Care” from category drop down.
By providing education and addressing common fears and concerns, these brief videos offer an alternative approach to patient engagement on these important topics. Take a look today!
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 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 on our website at empireblue.com/provider > Select Policies, Guidelines & Manuals under Provider Resources> scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Empire BlueCross BlueShield (“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:
- Discuss with the patient the importance of communicating with other treating practitioners.
- Obtain a signed release from the patient and file a copy in the medical record.
- Document in the medical record if the patient refuses to sign a release.
- Document in the medical record if you request a consultation.
- If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
- 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.**
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 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 BlueCross BlueShield (“Empire”) has adopted a Members’ Rights and Responsibilities statement.
The Members’ Rights and Responsibilities statement can be found on empireblue.com/FAQs > “Laws and Rights that Protect You”.
Practitioners may access the FEP member portal at www.fepblue.org/memberrights to view the FEPDO Member Rights Statement.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Our utilization management (UM) decisions are based on 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 BlueCross BlueShield’s (“Empire”) medical policies are available on empireblue.com/provider.
You can also request a free copy of our UM criteria from our medical management department, and each Treating and Ordering Provider directly involved in the members care may discuss a UM denial decision with a physician reviewer by calling us at the toll-free number listed on the UM denial letter, if they haven’t already done so, and before all applicable appeals are completed.
UM criteria are also available on the web. Just go to empireblue.com/provider > Provider Overview > View Medical Policies and Clinical UM Guidelines.
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.
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To discuss UM Process
and Authorizations
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To Discuss
Peer-to-Peer UM Denials w/Physicians
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To Request
UM Criteria
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TDD/TTY
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Business Hours
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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)
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Please refer to the phone number on the denial notification letter.
1-800-634-5605 – opt2 Pre-service Appeals
Adaptive Behavioral Treatment
1-844-269-0538
FEP: Phone 1-800-860-2156
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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)
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711
Or
TTY: 1-800-662-1220
Voice: 1-800-421-1220
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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.
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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.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form, on empireblue.com/provider.
The impact of COVID-19 in 2020 prohibited Empire BlueCross BlueShield (“Empire”) from conducting the annual appointment access studies to assess how well practices meet appointment access requirements for our members for behavioral healthcare (BH). We will resume the survey in second quarter 2021 and expect when your office is contacted, you will be able to accommodate a member’s needs in a timely manner.
To be compliant, per the Provider Manual, providers should meet the following access standards:
Non-life-threatening emergency: The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or a covering Practitioner within six hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate. Explanation: These calls concern members in acute distress, whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
Urgent: The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 48 hours. It can be after the Practitioners intake assessment or a direct referral from a treating Practitioner.
Explanation:- These calls are non-emergent with significant psychological distress, when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
Initial Routine office visit: A new patient must be seen in the office by a designated BH Practitioner or another equivalent Practitioner in the practice within 10 business days.
Explanation: This is a routine call for a new patient defined as a patient with non-urgent symptoms, which present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
Routine office visit:The patient must be seen in the office by their Practitioner, another Practitioner in the practice or by a covering Practitioner within 30 calendar days.
Explanation: These calls concern existing members, to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
BH follow-up appointment after discharge: The patient must be seen in the office by their Practitioner or another Practitioner in the practice within 5 calendar days of discharge from emergency, inpatient hospital care.
Explanation: These calls concern members being released from inpatient psychiatric hospital care, requesting a follow-up appointment to evaluate what has taken place since release, including med management.
Methods used to monitor adherence to these standards consist of assessing the accessibility of appointments via phone calls from North American Testing Organization, a vendor working on Empire’s behalf, and analysis of member complaint and member experience data.
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 March 14, 2021, the following updates will apply to the AIM Advanced Imaging of the Heart and Diagnostic Coronary Angiography Clinical Appropriateness Guidelines.
Evaluation of patients with cardiac arrhythmias
Updated repeat TTE criteria.
Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia.
Evaluation of signs, symptoms, or abnormal testing
Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature.
Diagnostic Coronary Angiography
Updated criteria to evaluate patients with suspected congenital coronary artery anomalies.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
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 March 14, 2021, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.
Chest Imaging and Head and Neck Imaging
- Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint
- Require laryngoscopy for the initial evaluation of all patients with primary voice complaint
Brain Imaging and Head and Neck Imaging
- Hearing loss
- Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is nondiagnostic or unable to be performed
- Higher allowed threshold for consecutive frequencies to establish SNHL
- Remove CT brain as an alternative to evaluating hearing loss based on ACR guidance
- Tinnitus
- Remove sudden onset symmetric tinnitus as an indication for advanced imaging
Head and Neck Imaging
- Sinusitis/rhinosinusitis
- Add more flexibility for the method of conservative treatment in chronic sinusitis.
- Require conservative management prior to repeat imaging for patients with prior sinus CT.
- Temporomandibular joint dysfunction
- Removed requirement for radiographs/ultrasound
- Cerebrospinal fluid (CSF) leak of the skull base
- Added scenario for management of known leak with change in clinical condition.
Brain Imaging
- Ataxia, congenital or hereditary
- Combine with congenital cerebral anomalies to create one section
- Acoustic neuroma
- More frequent imaging for a watch and wait or incomplete resection
- New indication for Neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2
- More frequent imaging when MRI shows findings suspicious for recurrence
- Single post-operative MRI following gross total resection
- Include pediatrics with known acoustics (rare but NF 2)
- Tumor – not otherwise specified
- Repurpose for surveillance imaging of low-grade neoplasms
- Seizure disorder and epilepsy
- Limit imaging for the management of established generalized epilepsy
- Require optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy
- Headache
- Remove response to treatment as a primary headache red flag
- Mental status change and encephalopathy
- Added requirement for initial clinical and lab evaluation to assess for a more specific cause
Oncologic Imaging
General enhancements: Updates to Scope/Definitions, general language standardization
General Content enhancements: Overall alignment with current national oncology guideline recommendations, resulting in:
- Removal of indications/parameters not addressed by NCCN
- Average risk inclusion criteria for CT Colonography
- New allowances for MRI Abdomen and/or MRI Pelvis by tumor type, liver metastatic disease
- New indications for Acute Leukemia (CT, PET/CT), Multiple Myeloma (MRI, PET/CT), Ovarian Cancer surveillance (CT), Bone Sarcoma (PET/CT)
- Updated standard imaging pre-requisites prior to PET/CT for Bladder/Renal Pelvis/Ureter, Colorectal, Esophageal/GE Junction, Gastric and Non-Small Cell Lung Cancers
- Additional PET/CT management scenarios for Cervical Cancer, Hodgkin Lymphoma
Other content enhancements by section:
- Cancer screening: New indication for Pancreatic Cancer screening
- Breast Cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment Breast MRI after breast conserving therapy or unilateral mastectomy
- Prostate Cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE
- Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
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 March 14, 2021, the following updates will apply to the AIM Radiation Oncology Clinical Appropriateness Guidelines.
Radiation Oncology
- Special Treatment Procedure
- Removed IV requirement for chemotherapy
- CNS cancer:
- IMRT for Glioblastomas, other gliomas and metastases: Eliminated the 3D plan comparison requirement. Same change for high-grade and low-grade gliomas.
- IMRT for Metastatic Brain Lesions: Added hippocampal sparing whole brain radiotherapy indication
- Lung cancer:
- Eliminated the plan comparison requirement for IMRT to treat stage III non-small cell lung cancer.
- SBRT: Removed “due to a medical contraindication” language
- SBRT: Added “as an alternative to surgical resection” to Stereotactic Body Radiation Therapy
- Adjusted fractionation maximum for curative treatment of non-small cell lung cancer up to 35 treatments of thoracic radiotherapy.
Proton Beam therapy
Added new indication for hepatocellular carcinoma and intrahepatic cholangiocarcinoma
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As communicated in the June and October 2020 editions of Provider News, effective December 1, 2020, Empire BlueCross BlueShield (“Empire”) will transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Rehabilitative Service Clinical Appropriateness Guidelines as part of the AIM Rehabilitation Program. Reviewed services will include certain physical therapy, occupational therapy and speech therapy services.
As part of this transition of clinical criteria, the following procedures will now be subject to prior authorization as part of the AIM Rehabilitation program:
|
CPT code
|
Description
|
|
90912
|
Biofeedback training for bowel or bladder control, initial 15 minutes
|
|
90913
|
Biofeedback training for bowel or bladder control, additional 15 minutes
|
|
96001
|
Three-dimensional, video-taped, computer-based gait analysis during walking
|
|
0552T
|
Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
|
|
S8940
|
Therapeutic horseback riding, per session
|
|
S8948
|
Treatment with low level laser (phototherapy) each 15 minutes
|
|
S9090
|
Vertebral axial decompression (lumbar traction), per session
|
|
20560
|
Needle insertion(s) without injection(s), 1 or 2 muscle(s)
|
|
20561
|
Needle insertion(s) without injection(s), 3 or more muscle(s)
|
|
90901
|
Biofeedback training by any modality (when done for medically necessary indications)
|
|
97129
|
One-on-one therapeutic interventions focused on thought processing and strategies to manage activities
|
|
97130
|
each additional 15 minutes (list separately in addition to code for primary procedure)
|
|
92630
|
Hearing training and therapy for hearing loss prior to learning to speak
|
|
92633
|
Hearing training and therapy for hearing loss after speech
|
The following procedure will be removed from the program:
|
S9117
|
back school, per visit
|
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective March 1, 2021, Empire BlueCross BlueShield (“Empire”) will update Bundled Services and Supplies section 1 coding list by removing the interprofessional CPT codes 99446, 99451, and 99452 to allow reimbursement for eConsults.
For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For participating Empire BlueCross BlueShield (“Empire”) commercial ASO plans, we have expanded our hospice benefit to align with our previous expansion for commercial fully insured members. These expanded hospice benefits allow members with a life expectancy of up to 12 months (increased from 6 months) and allow disease modifying treatments to continue alongside hospice services. If you have a patient with an advanced illness and life expectancy of less than 12 months, now is the time to talk about hospice. Hospice is a powerful support resource for patients that can work in tandem with their treatment.
Provider benefits:
- Improved communication: By removing obstacles to hospice care, providers can introduce hospice benefits earlier while empowering patients to express their goals, values and care preferences.
- Centralized care: The treating physician remains at the center of the patient’s overall treatment plan – supported by the entire hospice team. Patients get the benefit of expert medical care, pain management, and emotional and spiritual support all working together.
- Planning resource: Hospice professionals are a useful resource for physicians to help aid in discussions with patients and families related to: caregiver stress, fears of the future, end-of-life discussions and bereavement planning.
Patient benefits:
- More patient and caregiver support, earlier: Relaxing the previous benefit life expectancy maximum and treatment limitations will help patients with advanced illnesses access hospice services earlier, ultimately choosing the care that fits their personal needs.
Coordinated team: Patients will have a dedicated hospice team that coordinates access to medication, medical supplies, and equipment. Patients can depend on hospice services for their care needs rather than emergency room and intensive care professionals who are unfamiliar with their histories, goals, and preferences.
- Improved quality of life: Patients receive help sooner, manage their pain and symptom relief better, and families are able to discuss planning of personal needs more effectively.
Note: This update does not apply to Federal Employee Program® (FEP®), Medicare and
Medicaid. Providers should continue to verify eligibility and benefits for all Empire members prior to rendering services or referring members for hospice care.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In 2019, non-oncology medical specialty drug reviews were transitioned from AIM Specialty Health ® (AIM) to IngenioRx. We are implementing changes to the AIM IVR telephone prompts as they relate to IngenioRx medical specialty drug reviews.
Currently, if a provider calls into any of the existing AIM toll-free numbers for non-oncology medical specialty drug reviews, IVR telephone prompts are available informing the caller of the IngenioRx toll-free number, 1-833-293-0659. Callers are then automatically transferred to the IngenioRx number.
Beginning on January 1, 2021, the AIM toll-free numbers will no longer offer these IVR telephone prompts and transfer callers to IngenioRx for non-oncology medical specialty reviews. Providers must contact the IngenioRx review team directly:
- By phone at 1-833-293-0659
- By fax at 1-888-223-0550
- Online access at availity.com available 24/7.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Prior authorization updates
Effective for dates of service on and after March 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the Clinical Criteria information please click here.
Empire BlueCross BlueShield’s (“Empire”) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0179
|
J9999
|
Blenrep
|
|
ING-CC-0180
|
J3490, J3590, J9999
|
Monjuvi
|
|
ING-CC-0182
|
J1756
|
Venofer
|
|
ING-CC-0182
|
J2916
|
Ferrlecit
|
|
ING-CC-0182
|
J1750
|
Infed
|
|
ING-CC-0182
|
J1439
|
Injectafer
|
|
ING-CC-0182
|
Q0138
|
Feraheme
|
|
ING-CC-0182
|
J1437
|
Monoferric
|
Step therapy updates
Effective for dates of service on and after March 1, 2021, 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.
To access the Clinical Criteria information related to Step Therapy, please click here.
Empire’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS Codes
|
|
ING-CC-0182
|
Preferred
|
Venofer
|
J1756
|
|
ING-CC-0182
|
Preferred
|
Ferrlecit
|
J2916
|
|
ING-CC-0182
|
Preferred
|
Infed
|
J1750
|
|
ING-CC-0182
|
Non-preferred
|
Injectafer
|
J1439
|
|
ING-CC-0182
|
Non-preferred
|
Feraheme
|
Q0138
|
|
ING-CC-0182
|
Non-preferred
|
Monoferric
|
J1437
|
|
ING-CC-0174
|
Non-preferred
|
Kesimpta
|
J3490 (NOC)
|
|
ING-CC-0174
|
Non-preferred
|
Kesimpta
|
J3590 (NOC)
|
|
ING-CC-0174
|
Non-preferred
|
Kesimpta
|
C9399 (NOC)
|
Effective on or after January 1, 2021, documentation may be required to support step therapy reviews.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.
The following Clinical Criteria documents were endorsed at the October 23, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.
New Clinical Criteria effective October 30, 2020
The following clinical criteria is new.
- ING-CC-0181 Veklury (remdesivir)
Revised Clinical Criteria effective February 1, 2021
The following current clinical criteria was revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0011 Ocrevus (ocrelizumab)
Revised Clinical Criteria effective March 1, 2021
The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0078 Orencia (abatacept)
- ING-CC-0174 Kesimpta (ofatumumab)
New Clinical Criteria effective March 1, 2021
The following clinical criteria is new.
- ING-CC-0182 Agents for Iron Deficiency Anemia
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the October 2020 edition of Provider News, Empire BlueCross BlueShield (“Empire”) notified providers about a new billing requirement to help us determine the correct amount to pay on drug claim lines for commercial professional and facility outpatient claims filed to us.
As a reminder, effective for dates of service on and after December 11, 2020, the following information will be required on claims for all categories of drugs except for those administered in an inpatient facility setting:
- Applicable HCPCS code or CPT code
- Number of HCPCS code or CPT code units
- Valid 11-digit National Drug Code(s) (NDC), including the N4 qualifier
- Unit of Measurement qualifier (F2, GR, ML, UN, MG)
- NDC units dispensed (must be greater than 0)
Note: These billing requirements apply to Local Plan and BlueCard® only. This notice EXCLUDES claims for members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP) and Coordination of Benefits/secondary claims.
As we shared in the original notification, Empire will deny any line items on a claim regarding drugs that do not include the above information – effective for dates of service on and after December 11, 2020. Please include the above information on drug claims to help ensure accurate and timely payments.
If you have further questions, please contact the telephone number on the back of the member’s ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit empireblue.com/pharmacyinformation. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate Marketplace, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield HealthPlus is now using the Notification Center on the Availity* Portal home page to communicate vital and time sensitive information. You will see a Take Action call out and a red flag in front of the message to make it easy to see new items requiring your attention.
Viewing the Notification Center updates should be included as part of your regular workflow so that you are aware of any outstanding action items.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Introducing the Empire Provider Digital Engagement Supplement to the provider manual
Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered via the Availity EDI website or the secure Provider Portal via Availity.
Get payments faster
By eliminating paper checks, Electronic Funds Transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.
Member IDs go digital
Empire BlueCross BlueShield (“Empire”) members are transitioning to digital member identification cards making it easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.
Empire makes going digital easy with the Provider Digital Engagement Supplement
From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.empireblue.com/ny/pages/communications-updates.aspx > Communications & Updates > Communications and Updates > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.
The Provider Digital Engagement Supplement to the provider manual is another example of how Empire is using digital technology to improve the health care experience. We are asking providers to go digital with Empire no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Provider Digital Engagement Supplement now by going to https://mediproviders.empireblue.com/ny/pages/communications-updates.aspx > Communications & Updates > Communications and Updates > Provider Digital Engagement, and go digital with Empire.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In order to communicate more efficiently with providers, Empire BlueCross BlueShield HealthPlus (Empire) is now sending some bulletins, policy change notifications, prior authorization update information, educational opportunities and more to providers via email. Email is the quickest and most direct way to receive important information from Empire.
What do we need from you?
To receive email from Empire (including some sent in lieu of fax or mail), submit your information via the contact form located on the provider site: www.empireblue.com/nymedicaiddoc > Provider Support > Other Training Resources > Forms > Sign up to receive email communications.
When multiple email addresses, NPIs or TINs exist, you need to submit all of the required fields separately for each individual provider or provider within a group. However, please keep in mind that we can only accept one email address for each unique provider record.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Network Relations Consultant or call Provider Services at 1-800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® is an annual standardized survey conducted to assess consumer experience with their health care services and health plan. Providers and their staff play a key role in the member experience. Several questions specific to the member’s experience with their provider are included in the CAHPS survey. Education about the CAHPS survey, the importance of focusing on the patient experience and ways to improve the patient experience are included in the Provider Orientation and available by visiting www.empireblue.com/nymedicaiddoc.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Across the nation, too many women continue to experience pregnancy-related complications and death. More than 700 women die each year in the United States as a result of complications related to pregnancy or delivery. 1 Many of these deaths are preventable. In addition, significant racial and ethnic disparities exist in maternal morbidity and mortality. For example, Black/African American and American Indian/Alaska Native women are two to three times more likely to die from pregnancy-related complications compared to White women. 2 Empire BlueCross BlueShield HealthPlus recognizes your role at the front lines of defense to support your diverse pregnant and postpartum patients. We want to ensure you have the right tools and resources to help your patients understand their risks and key maternal warning signs.
The Centers for Disease Control and Prevention (CDC) recently launched the Hear Her campaign to raise awareness of pregnancy-related complications, risks and death. The Hear Her campaign aims to increase knowledge of the symptoms women should seek medical attention for during pregnancy and in the year after delivery, such as vision changes and chest pain. Resources are available for pregnant and postpartum women, partners, families and friends, and health care providers.
The Hear Her campaign reminds us of the importance of listening to women. As a health care provider, you have an opportunity to listen to pregnant women, engage in an open conversation to make certain their concerns are adequately addressed, and help your patients understand urgent maternal warning signs. You can find more information on the CDC's Hear Her campaign at www.cdc.gov/hearher.
In addition, the Council on Patient Safety in Women's Health Care developed a tool to help women identify urgent maternal warning signs. The Urgent Maternal Warning Signs tool helps women recognize the symptoms they may experience during and after pregnancy that could indicate a life-threatening condition. The tool also provides additional information on the symptoms and conditions that place women at increased risk for pregnancy-related death. You can find the Council on Patient Safety in Women's Health Care Urgent Maternal Warning Signs tool at www.safehealthcareforeverywoman.org/urgentmaternalwarningsigns.
If you have a pregnant member in your care who would benefit from case management, please call us at 1‑800‑450-8753. Members can also call our 24/7 NurseLine at the number on their member ID card.
References
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective November 1, 2020, Empire BlueCross BlueShield HealthPlus (Empire) now reimburses both capitated and fee-for-service contracted providers for flu vaccine services.
We are aligning our reimbursement policy with the New York State Department of Health’s communication regarding flu vaccine codes and will reimburse for the following CPT® codes:
|
90653
|
90654
|
90656
|
90658
|
|
90674
|
90682
|
90685
|
90686
|
|
90673
|
90672
|
90756
|
90662
|
|
90630
|
90687
|
90688
|
90694
|
If you provided flu vaccine service to an Empire member prior to receipt of this notice and did not include the service on the claim, please submit a corrected claim (not a new claim) with the applicable code(s) to receive both the additional reimbursement and the credit for the quality measure.
If you have questions about this communication or need assistance with any other item, call Provider Services at 1-800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Reimbursement policies serve as a guide to assist you with accurate claim submissions and outline the basis for reimbursement if services are covered by the member’s Empire BlueCross BlueShield HealthPlus (Empire) benefit plan. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence. Covered services do not guarantee reimbursement unless specific criteria are met.
You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claims submissions. Services should be billed with CPT® codes, HCPCS codes and/or revenue codes. The codes denote the service and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed, Empire may:
- Reject or deny the claim.
- Recover and/or recoup claim payment.
- Adjust the reimbursement to reflect the appropriate services and/or procedures performed.
Empire reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by provider or state contract language or state/federal requirements or mandates. System logic or set-up may prevent the loading of policies into the claims platforms in the same manner as described; however, Empire strives to minimize these variations.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Introducing the Empire Provider Digital Engagement Supplement to the provider manual
Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered via the Availity EDI website or the secure Provider Portal via Availity.
Get payments faster
By eliminating paper checks, Electronic Funds Transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.
Member IDs go digital
Empire BlueCross BlueShield (“Empire”) members are transitioning to digital member identification cards making it easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.
Empire makes going digital easy with the Provider Digital Engagement Supplement
From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.empireblue.com/ny/pages/communications-updates.aspx > Communications & Updates > Communications and Updates > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.
The Provider Digital Engagement Supplement to the provider manual is another example of how Empire is using digital technology to improve the health care experience. We are asking providers to go digital with Empire no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Provider Digital Engagement Supplement now by going to https://mediproviders.empireblue.com/ny/pages/communications-updates.aspx > Communications & Updates > Communications and Updates > Provider Digital Engagement, and go digital with Empire.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. How do I check eligibility and benefits for these members?
Online — Eligibility, benefits, claims, links to secure messaging, commonly used forms and remit information are all available through the Availity* Portal at https://www.availity.com. For questions on access and registration, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548). Availity Client Services is available Monday through Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration questions.
Phone — Call the Provider Service number on the back of the member’s ID card. You may also verify a member’s eligibility by calling the BlueCard Eligibility Line at 1‑800‑676‑BLUE (2583) and providing the member’s three-digit alpha prefix located on the ID card.
As new members enroll in Group Retiree Medicare Advantage plans under Empire BlueCross BlueShield, they will receive new ID cards. Additionally, existing members may receive new ID cards as a result of benefit changes. Please continue to check member ID cards to ensure you have the most up-to-date eligibility and benefit information.
Please note that we are experiencing an unusually high volume of changes for an effective date of January 1, 2021. Many of the changes do not affect member prefix, member ID or benefits, but some changes will. Because of this, we encourage providers to request a copy of the member’s ID card, particularly at the beginning of the year when members may have new ID cards.
What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?
- AFJ
- CBH
- MEW, MBL
- VAY, VGD
- WSP, WZV
- XLU, XNS
- YVK, YGZ
- ZDX, ZMX, ZVR, ZVZ
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 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 members of your practice and office staff.
To view a guideline, visit https://www11.empireblue.com/ny_search.html.
Updates
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- 00134 — Noninvasive Heart Failure and Arrhythmia Management and Monitoring System:
- Revised Investigational and Not Medically Necessary indications
- 00156 — Implanted Artificial Iris Devices:
- Revised Investigational and Not Medically Necessary indications
- 00157 — Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis:
- Revised Investigational and Not Medically Necessary indications
- CG-DME-07 — Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output:
- Revised Medically Necessary and Not Medically Necessary indications
- 00052 — Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
- Revised Medically Necessary indications
- 00077 — Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques:
- Expanded scope and revised Investigational and Not Medically Necessary indications
- 00112 — Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures):
- Revised scope, and Investigational and Not Medically Necessary indications
- CG-REHAB-12 — Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology:
- A new clinical UM Guideline was created from content contained in CG-REHAB-04,
CG-REHAB-05, CG-REHAB-06.
- There are no changes to the guideline content.
- Publish date is scheduled for December 8, 2020.
The following AIM Specialty Health®* Clinical Appropriateness Guidelines have been revised and will be effective on December 6, 2020. To view AIM guidelines, visit the AIM Specialty Health page:
- Interventional Pain Management (See August 16, 2020, version.)*
- Chest Imaging (See August 16, 2020, version.)*
- Oncologic Imaging (See August 16, 2020, version.)*
- Sleep Clinical Guidelines (See August 16, 2020, version.)*
Medical Policies
On August 13, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield (Empire). These guidelines take effect December 6, 2020.
|
Publish date
|
Medical Policy #
|
Medical Policy title
|
New or revised
|
|
10/7/2020
|
*MED.00134
|
Non-invasive Heart Failure and Arrhythmia Management and Monitoring System
|
New
|
|
10/7/2020
|
*SURG.00156
|
Implanted Artificial Iris Devices
|
New
|
|
10/7/2020
|
*SURG.00157
|
Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
|
New
|
|
9/1/2020
|
*GENE.00052
|
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
|
Revised
|
|
10/7/2020
|
*SURG.00077
|
Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
|
Revised
|
|
10/1/2020
|
*SURG.00112
|
Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
|
Revised
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Clinical UM Guidelines
On August 13, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines adopted by the medical operations committee for our members on September 24, 2020. These guidelines take effect December 6, 2020.
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Publish date
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Clinical UM Guideline #
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Clinical UM Guideline title
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New or revised
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10/7/2020
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*CG-DME-07
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Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output
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Revised
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10/7/2020
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CG-DME-25
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Seat Lift Mechanisms
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Revised
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8/20/2020
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CG-GENE-03
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BRAF Mutation Analysis
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Revised
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8/20/2020
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CG-SURG-83
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Bariatric Surgery and Other Treatments for Clinically Severe Obesity
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Revised
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |