As we announced in the October 2021 edition of Provider News, Empire BlueCross BlueShield (“Empire”) is working to comply with the requirements of the Consolidated Appropriations Act, or CAA.

 

Improving the accuracy of provider directory information

As part of the CAA, soon providers will be asked to verify their online provider directory information on a regular basis to help ensure Empire members can locate the most current information for in-network providers and facilities. It is important that you keep your information up to date. Here’s what you can do now:

• Review your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Empire’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to empireblue.com/providers, then under Provider Overview, choose Find Care.
• Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
  • add/change an address location
  • name change
  • tax ID changes
  • provider leaving a group or a single location
  • phone/fax number changes
  • closing a practice location

Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

 

Consolidated Appropriations Act implementation

The Consolidated Appropriations Act does not preempt state law requirements. This means that the CAA applies in addition to any state l aw requirements of providers to update their provider directory information.

 

On August 20, 2021, the Tri-Agencies (Departments of Labor, Health and Human Services and the Treasury) announced that regulations to implement the provider directory requirements would be issued on or after January 1, 2022. Health plans are expected to implement the provider directory requirements based on a good faith, reasonable interpretation of the requirements by January 1, 2022, with a primary focus on ensuring that members who rely on provider directory information that inaccurately depicts a provider’s network status are only liable for in-network cost sharing amounts. Anthem is moving forward with compliance of this good faith, reasonable interpretation of the requirements while awaiting additional regulatory guidance.

 

Watch for upcoming editions of Provider News in 2022 for updates on our ongoing efforts to comply with the CAA requirements.

 

1453-1221-PN-NY

 

Contracted facilities may request to electronically receive Utilization Management (UM) verbal notices. These notices are required under Article 49 of the Public Health Law and Insurance Law for preauthorization and concurrent utilization review determinations, rather than via phone calls.  Electronic notices are transmitted via the daily Last Approved Day (LAD) report and/or Availity, which are also in addition to UM determination written letter notices.

 

Facilities may update their preference for UM verbal notices by completing Empire’s “Verbal UM Notifications Preference” form with the appropriate authorized signature.  Facilities may access Empire’s “Verbal UM Notifications Preference” form here.

 

By updating preference to receive UM notices electronically, rather than by phone call,

• Facilities will still receive a daily LAD report, if they receive currently
• Facilities will still receive UM determination written letter notifications
• Facilities will still have access to UM decisions via Availity / Provider Portals
• Facilities may contact Network Management to opt back into phone notices, at any time

 

1457-1221-PN-NY

 

 

You may already be familiar with the Availity multi-payer Authorization app because thousands of providers are already using it for submitting prior authorizations for other payers. Empire BlueCross BlueShield (“Empire”) is eager to make it available to our providers, too. On December 13, 2021, you can begin using the same authorization app you use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Empire.

 

ICR is still available

If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We’ve developed a pathway to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization app.

 

Innovation in progress

While we grow the Availity Authorization app to provide you with Empire-specific information, you can still access ICR for:

• Appeals
• Behavioral health authorizations
• FEP authorizations
• Medical specialty Rx

 

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

 

Training is available

If you aren’t already familiar with the Availity Authorization app, training is available.

 

Wednesday, December 1, 2021	11:00 a.m. ET
Wednesday, December 8, 2021	12:00 p.m. ET
Friday, December 17, 2021	2:30 p.m. ET
Wednesday January 5, 2022	11:00 a.m. ET
Tuesday, January 11, 2022	3:00 p.m. ET

 

You can always log onto Availity.com and view the webinar at your convenience. From Help & Training select Get Trained to access the Availity Learning Center. You can use “AvAuthRef” for a keywork search or select the Session tab to see all upcoming live webinars.

 

Now, give it a try!

Accessing the Availity Authorization app is easy. Just log onto Availity.com and the Authorization icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

 

1467-1221-PN-NY

 

When you use the Availity Authorization app, you will know if a prior authorization is required in six easy steps and in fewer than five minutes. If a prior authorization is not needed, the message “No Auth Required” will return. This submission will be saved to your dashboard for future reference. If authorization is needed, just continue with the prior authorization submission. The entire submission process takes less time than it would to send an authorization by fax and is much quicker than chatting with provider services.

 

Did you know that digital authorizations are considered a high priority? Submitting your pressing authorizations through the Availity Authorization app augments our process, helping to reduce unnecessary delays to your patient’s care.

 

You can now submit prior authorizations in one place for all payers. The Availity Authorization app is multi-payer. This means you no longer have to toggle between Empire BlueCross BlueShield’s (“Empire”) Interactive Care Reviewer (ICR) and the Availity Authorization app to submit apps for all payers.

 

AIM authorization for radiology services? No problem! The Availity Authorization app is set up for radiology service authorization submissions. Coming in 2022, you can submit all of your AIM authorizations through the app.

 

Access the Availity Authorization app for Empire submissions on December 13, 2021. Log onto Availity.com on December 13, 2021, and select the Authorizations app from the home screen or use the Patient Registration tab to select Authorizations & Referrals through the multi-payer app.

 

ICR is still accessible to review previously submitted authorizations. You will also continue to use ICR for behavioral health authorizations, FEP authorizations and authorizations for medical specialty Rx. Until we fully integrate Empire-specific functions in the Availity Authorization app, you will also continue to use ICR for appeals as well.

 

How do you access ICR? That’s easy, too. We have added a landing page in the Availity Authorization app that offers a direct link to your ICR dashboard. Just select the Reserved Auth/Appeals button on the landing page.

 

Not familiar with the Availity Authorization app? Training is convenient and available through live webinars or recorded sessions for self-service learning. To sign-up for training log onto Availity.com and from the top toolbar select Help & Training then Get Trained. Use “AvAuthRef” in the search bar or select the Session tab to see all upcoming live webinars.

 

Availity Authorization app training schedule:

Now, give it a try! If you’re not enrolled on Availity go to Availity.com/provider-portal-registration. Availity is free to Empire providers, saves time, reduces costs and offers a seamless digital transaction experience.

 

Wednesday, December 1, 2021	11:00 a.m. ET
Wednesday, December 8, 2021	12:00 p.m. ET
Friday, December 17, 2021	2:30 p.m. ET
Wednesday January 5, 2022	11:00 a.m. ET
Tuesday, January 11, 2022	3:00 p.m. ET

 

1468-1221-PN-NY

 

Talking to a teenager about Chlamydia can be difficult. But, if untreated, the typical teenager could develop Pelvic Inflammatory Disease (PID) or worse, infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. For a free Chlamydia How-To  Implementation Guide for Healthcare Providers, visit the National Chlamydia Coalition website at  http://chlamydiacoalition.org.

 

One of the largest growing populations for Chlamydia is teens and young adults aged 15 to 24. Through annual screening – a simple urine test in your office or in an off-site lab – teens and young adults can maintain good health.Chlamydia Screening in Women (CHL): HEDIS® recommends annual screenings for teens starting at age 16 and for women up to age- 24. Sexually active teens and women as well as those who meet any of the following criteria should be tested each calendar year:

• Made comments or talked to you about sexual relations
• Taken a pregnancy test
• Been prescribed birth control (even if used for acne treatment)
• Received Gynecological services
• A history of sexually transmitted diseases
• A history of sexual assault or abuse

 

Description	CPT Codes
Chlamydia tests	87110, 87270, 87320, 87490, 87491, 87492, 87810
Pregnancy test exclusion	81025, 84702, 84703

 

1471-1221-PN-NY

 

As a reminder, Empire BlueCross BlueShield (“Empire”) will continue to upgrade our claim editing software for outpatient facility services monthly throughout 2022, with most updates occurring quarterly. These upgrades will include, but are not limited to:

 

• Addition of new and revised codes (for example CPT, HCPCS, ICD-10, modifiers, and revenue codes) and their associated edits

• Updates related to the appropriate use of various code combinations, which can include, but are not limited to:

• Procedure code to revenue code
• HCPCS to revenue code
• Type of bill to procedure code
• Type of bill to HCPCS code
• Procedure code to modifier
• HCPCS to modifier

• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC)

 

1459-1221-PN-NY

 

As a reminder, we will continue to upgrade our claim editing software for professional services monthly throughout 2022, with most updates occurring quarterly. These upgrades may apply to same provider, provider group (tax identification number). They may also apply across providers and across claim types (professional/facility) and include, but are not limited to:

• addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits such as:
  • ICD-10 laterality and Excludes1 notes
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (e.g. “separate procedure”, “do not report”, “list separately in addition to”, etc...)
• updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• updates to assistant and co-surgeon eligibility in accordance with the policy
• updates to edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

 

1458-1221-PN-NY

 

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 Review Policies, scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

 

1451-1221-PN-NY

 

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:

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:

In an effort to facilitate coordination of care, Empire has several tools available on our Provider website, empireblue.com for behavioral health and other medical practitioners including:

• Coordination of Care Form
• Coordination of Care Letter Template - Behavioral Health
• Coordination of Care Letter Template - Medical

 

The following behavioral health forms, brochures, and screening tools for substance abuse and attention-deficit/hyperactivity disorder (ADHD) are also available on empireblue.com. 

• Alcohol Use Assessment Brochure
• Antidepressant Medication Management
• Edinburgh Postnatal Depression Scale
• Opioid Use Assessment Brochure
• Substance Brief Intervention/Referral Tool (SBIRT)
• Vanderbilt ADHD Diagnostic Parent Rating Scale

 

1450-1221-PN-NY

 

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 member rights and responsibilities statement.

 

To read the member rights and responsibilities statement, visit the Policies, Guidelines and Manuals page of our provider empireblue.com/provider. Scroll down the page and select “Read about member rights.” Under the FAQ question titled “Laws and Rights that Protect You” you can find information about Empire member rights and responsibilities.

 

Practitioners may access the FEP member portal at fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

 

1449-1221-PN-NY

 

Empire BlueCross BlueShield (“Empire”) 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’s medical policies are available on our website at empireblue.com.

 

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 member’s 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 > For Providers > Provider Resources > Policies, Guidelines & Manuals > 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. to 5 p.m. ET. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
• 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 12 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 Authorization	To Discuss Peer-to-Peer UM Denials w/Physician	To Request UM Criteria	TTY/TDD
800-982-8089   Transplant 800-255-0881 National Transplant 844-644-8101 Fax: 888-438-7051   Behavioral Health 800-626-3643   Autism 844 269 0538   FEP 800-860-2156  Fax: 800 732-8318 (UM) Fax: 877 606-3807 (ABD	Please refer to the phone number on the denial notification letter.      Pre-service Appeals 800-634-5605, option 2   Adaptive Behavioral Treatment 844-269-0538   FEP 800-860-2156	Call number on back of member’s ID card   FEP 800-860-2156  Fax: 800-732-8318 (UM) Fax: 877-606-3807 (ABD)	711, or TTY: 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.

 

 1445-1221-PN-NY

 

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	CM Telephone Number	CM Business Hours
ECM-NY@Empireblue.com	1-800-563-5909	Mon – Fri 8:30 am – 7:00 pm EST
nationalpriorityrefe@ChooseHMC.com	1-855-239-0364 1-800-255-0881 (Transplant)	Mon - Friday 8am-9pm EST, Saturday 9am-5:30pm EST          Mon-Friday 8:30am-5pm EST (Transplant)
FEP.Care.Coordination@anthem.com	1-800-711-2225	9am-5pm in members time zone

 

1446-1221-PN-NY

 

The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Empire BlueCross BlueShield (“Empire”) plans assessed fell short of the expectation of having a live person or a directive in place after hours.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

• inaccurate provider information in Empire’s demographic database to allow assessment of the after-hours messaging
• no voicemail or messaging at all
• voicemail not reflecting the practitioner’s name, and/or
• calls being auto forwarded with no identification, no voicemail or messaging

 

To help both your patients’ and Empire’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

 

What does this mean for our members and your patients? The annual member experience survey of Empire enrollees indicated of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these three steps:

1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
2. Be sure to turn on the messaging mechanism when you leave the office.
3. Be sure you are using the acceptable messaging for compliance with your contract.

 

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

 

Emergency situations

Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER.  

 

Urgent situations

Compliant responses for urgent needs after hours:

• Live person, via a service or hospital, advises practitioner or on call practitioner is available and connects.
• Live person or recording directs caller/patient to Urgent Care, ER or call 911.

 

Non-compliant responses for urgent needs after hours:

• No provision for after-hours accessibility.
• Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. (Not a direct connection to their practitioner.)

 

Is your practice compliant?

 

1482-1221-PN-NY

The annual behavioral health access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded during the first through third quarters of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine follow-ups.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Empire BlueCross BlueShield’s (“Empire”) demographic database, i.e. incorrect or non-working phone numbers; practitioner moved, retired, or deceased; the practice has resigned their Empire contract, accepts private pay only, or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Empire’s contract.

 

The primary appointment type not meeting compliance is consistently obtaining the initial routine appointment. This is the initial conversation with a professional after the intake assessment for a new patient for a non-urgent condition. Please refer to compliant timeframe and explanation below.

 

To be compliant, per the Provider Manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:

• Non-life-threatening emergency – The patient must meet with their BH practitioner, another practitioner in the practice or a covering practitioner within 6 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 meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 48 hours.
  • 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 meet with a designated BH practitioner or another equivalent practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating practitioner.
  • Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms which presents no immediate distress, and can wait to schedule an appointment without any adverse outcomes.
• Routine office visit – The patient must meet with their BH 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 meet with their practitioner or another practitioner in the practice within 5 calendar days.
  • 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.

 

1481-1221-PN-NY

 

As communicated in the November 2021 issue of Provider News, the 32BJ Health Fund has partnered with hospitals and providers in New York, New Jersey, Connecticut, Massachusetts, Pennsylvania, and Florida to implement a Centers of Excellence (COE) Program for Bariatric and Joint Replacement surgeries starting on January 1, 2022.

 

Important features of the program include:

• Coverage for 32BJ members: 32BJ Health Fund plan participants will only have coverage for their bariatric or joint replacement procedures when performed by a COE-participating provider at a COE hospital. Participants will have a $0 copay for the procedure and follow-up care within 30 days. There will be no coverage for bariatric and joint replacement surgeries performed by a non-COE provider or at a non-COE hospital.
• To locate a COE provider and COE hospital: Plan participants may call 32BJ Member Services at (800) 551-3225. Providers may call Empire Provider Services at (800) 676-2583.
• Distance threshold: 32BJ plan participants living within 50 miles of a COE hospital must have their surgery performed by a COE provider at a COE hospital. More than 90% of 32BJ members live within 50 miles of a COE hospital.

 

You can easily identify 32BJ plan participants by the unique prefix on their Empire ID, “ETRBJ.”

 

Any provider looking for more information—particularly anyone currently caring for 32BJ plan participants who may be candidates for bariatric or joint replacement surgery—should call Empire Provider Services at 1-800-676-2583.

 

1487-1221-PN-NY

For more than a decade, Blue Precision – Empire BlueCross BlueShield’s (“Empire”) physician transparency program – has recognized specialists for meeting or exceeding established quality and cost effectiveness measures.  Thank you to all those physicians participating in our networks and for the care you provide to our members. 

 

As we announced in the July 2021 edition of Provider News, Empire has made the business decision to retire our Blue Precision program effective December 31, 2021.  Blue Precision recognition icons and other program information will be removed from empireblue.com> and our “Find Care” provider tool by January 1, 2022.

 

Going forward, Empire will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.  We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare. 

 

1419-1221-PN-NY

Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT^® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override. 

 

For additional information, please review the Drug Screen Testing reimbursement policy at https://providerpublic.empireblue.com.

 

NYE-NU-0360-21 October 2021

 

Effective March 1, 2022, outpatient facilities that are reimbursed with percent of charge methodology will apply the multiple surgery reduction. The reductions are listed in the Multiple Surgery section of the policy.

 

For additional information, please review the Multiple and Bilateral Surgery - Professional and Facility reimbursement policy at https://providerpublic.empireblue.com.

 

NYE-NU-0368-21 October 2021

 

The following HEDIS^® measures assess the percentage of emergency department (ED) visits for which the member received a follow-up appointment within seven days and 30 days of being seen in the ED for mental illness or for alcohol and other drug dependence.

 

Follow-Up After ED Visit for Mental Illness (FUM)

Evaluates the percentage of ED visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit with any practitioner for mental illness. Two rates are reported. The percentage of ED visits for which the member received:

1. Follow-up within seven days of the ED visit.
2. Follow-up within 30 days of the ED visit.

 

Timely follow-up care for people with mental illness can lead to fewer repeat visits to the ED and improved physical and mental health function.

 

Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence (FUA)

Evaluates the percentage of ED visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit with any practitioner for AOD. Two rates are reported. The percentage of ED visits for which the member received:

1. Follow-up within seven days of the ED visit.
2. Follow-up within 30 days of the ED visit.

 

According to studies, follow-up care for individuals with AOD who were seen in the ED is associated with reduced substance use, repeat ED visits, and hospital admissions.

 

Helpful tips:

• Maintain appointment availability for patients with recent ED visits.
• Assist in scheduling in-person or telehealth follow-up appointments as soon as possible after the ED visit.
• Use appropriate documentation and correct coding. Use the same diagnosis for mental illness or substance use for follow-up visits (a non-mental health/non-substance diagnosis code will not fulfill the measure).
• Reference the plan’s Quality Measures Desktop Reference for Medicaid Providers and the HEDIS® Benchmarks and Coding Guidelines for Quality that is provided for coding information.
• Educate patients on the importance of compliance with their discharge plan and their follow-up appointments.
• Reach out to patients who cancel their appointments and assist with rescheduling as soon as possible.
• Facilitate referrals to behavioral healthcare specialists when appropriate.

 

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

 

NYE-NU-0361-21 October 2021

Beginning with dates of service on or after January 1, 2022, Empire BlueCross BlueShield HealthPlus will implement revised claims editing logic tied to Excludes1 notes from ICD-10-CM 2020 coding guidelines. To ensure the accurate processing of claims, use ICD-10-CM coding guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the category level that a code can be billed with another range of codes, it is imperative to look for Excludes1 notes that may prohibit billing a specific code combination.

 

If you need assistance in determining proper coding guidance, the following site should be helpful: https://www.cdc.gov/nchs/icd/icd10cm.htm.

 

What are Excludes1 notes?

One of the unique attributes of the ICD-10-CM code set and coding conventions is the concept of Excludes1 notes. An Excludes1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes1 note. These notes appear below the affected codes; if the note appears under the Category (first three characters of a code), it applies to the entire series of codes within that category. If the Excludes1 note appears beneath a specific code (3, 4, 5, 6, or 7 characters in length), then it applies only to that specific code.

 

Examples

In ICD-10-CM, when a category includes an Excludes1 note, it outlines what codes should not be billed together. Examples of this code scenario would include but are not limited to the following:

• Reporting Z01.419 with Z12.4
  • 4Z0.41X (encounter GYN exam w/out abnormal findings) has an Excludes1 note below that includes Z12.4 (encounter for screening malignant neoplasm cervix).
• Reporting Z79.891 with F11.2X
  • Z79.891 (long-term use of opiates) has an Excludes1 note below it that includes F11.2X (opioid dependence).
• Reporting M54.2 with M50.XX
  • M54.2 (cervicalgia) has an Excludes1 note below it that includes M50.XX (cervicalgia due to intervertebral disc disorder).
• Reporting M54.5 with S39.012X and/or M54.4x and/or M51.2X
  • MS4.5 (low back pain) has an Excludes1 note below it that includes:
    • S39012X (strain of muscle, fascia and tendon of lower back)
    • M54.4X (low back pain)
    • M51.2X (lumbago due to intervertebral disc disorder)
• Reporting F32 with F30, F31, or F33
  • F32 (Major Depressive disorder, single episode) has an Excludes1 note below that includes:
    • F30 (manic episode)
    • F31 (bipolar disorder)
    • F33 (recurrent depressive disorder)
• Reporting J03.XX with J02.XX, J35.1, J36, J02.9
  • J03. (Acute tonsillitis) has an Excludes1 note below it that includes:
    • J02 (acute sore throat)
    • J35.1(hypertrophy of tonsils)
    • J36 (Peritonsillar abscess)
• Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, A59.00
  • N89 (Other inflammatory disorders of the vagina) has an Excludes1 note below that includes:
    • R87.62X (abnormal results from vaginal cytological exam)
    • D07.2 (vaginal intraepithelial neoplasia)
    • R87.623 (HGSIL of vagina)
    • N76.XX inflammation of the vagina)
    • N95.2 (senile [atrophic] vaginitis)
    • A59.00 (trichomonal leukorrhea)
• Reporting F91 with Z72.81 or F60.2
• F91 (conduct disorder) has an Excludes1 note below it that includes Z72.81 (antisocial behavior),
• F60.2 (Antisocial personality)
• Reporting O26.843 with Z03.74
  • O26.843 (uterine size-date discrepancy, third trimester) has an Excludes1 note below it that includes:
    • Z03.74 (encounter for suspected problem with fetal growth ruled out)

 

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM code book to verify appropriate use of the billed codes and provide supporting documentation through the normal claim payment dispute process as to why the billed diagnoses codes are appropriately used together.

If you have questions about this communication or need assistance with any other item, call Provider Services at 800-450-8753 or contact your local Provider Experience Consultant.

 

NYE-NU-0375-21 October 2021

 

Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health_® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Updates by guideline:

• Imaging of the Brain:

• Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
• Meningioma — new guideline establishing follow-up intervals
• Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
• Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

• Imaging of the Head and Neck:
  • Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
  • Temporomandibular joint dysfunction — specified duration of required conservative management
• Imaging of the Heart:
  • Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
• Imaging of the Chest:
  • Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
  • Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
• Imaging of the Abdomen and Pelvis:
  • Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
  • Intussusception — removed as a standalone indication
  • Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
  • Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
  • Azotemia — removed as a standalone indication
  • Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline

• Diffuse liver disease – new indication for multiparametric MRI for fibrosis and hemochromatosis

• Oncologic Imaging:
  • National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and Non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
  • Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
  • Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

 
As a reminder, ordering and servicing providers may siubmit prior authorization requests to AIM via:

AIM’s ProviderPortal_SM directly at providerportal.com.
The Availity* Portal at availity.com.
Phone at 855-574-6481, Monday through Friday from 8 a.m. to 8 p.m. ET.

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield HealthPlus. Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0377-21 October 2021

 

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://www.empireblue.com/provider/policies/clinical-guidelines/search.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *CG-SURG-112 — Carpal Tunnel Decompression Surgery
  • Outlines the Medically Necessary and Not Medically Necessary criteria for carpal tunnel decompression surgery
• *CG-SURG-113 — Tonsillectomy with or without Adenoidectomy for Adults
  • Outlines the Medically Necessary and Not Medically Necessary criteria
• *DME.00043 — Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
  • The use of a neuromuscular electrical training device is considered Investigational & Not Medically Necessary for the treatment of obstructive sleep apnea or snoring
• *GENE.00058 — TruGraf Blood Gene Expression Test for Transplant Monitoring
  • TruGraf blood gene expression test is considered Investigational & Not Medically Necessary for monitoring immunosuppression in transplant recipients and for all other indications
• *LAB.00040 — Serum Biomarker Tests for Risk of Preeclampsia
  • Serum biomarker tests to diagnosis, screen for, or assess risk of preeclampsia are considered Investigational & Not Medically Necessary
• *LAB.00042 — Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
  • Molecular signature testing to predict response to Tumor Necrosis Factor inhibitor (TNFi) therapy is considered Investigational & Not Medically Necessary for all uses, including but not limited to guiding treatment for rheumatoid arthritis
• *OR-PR.00007 — Microprocessor Controlled Knee-Ankle-Foot Orthosis
  • Outlines the Medically Necessary and Not Medically Necessary criteria for the use of a microprocessor controlled knee-ankle-foot orthosis
• *SURG.00032 — Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
  • Added Medically Necessary statement for transcatheter closure of left atrial appendage (LAA) for individuals with non-valvular atrial fibrillation for the prevention of stroke when criteria are met
  • Revised Investigational & Not Medically Necessary statement for transcatheter closure of left atrial appendage when the criteria are not met
• *SURG.00077 — Uterine Fibroid Ablation: Laparoscopic, Percutaneous, or Transcervical Image Guided Techniques
  • Added Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation
  • Added Not Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation when criteria in Medically Necessary statement are not met
  • Removed laparoscopic radiofrequency ablation from Investigational & Not Medically Necessary statement
  • Removed Investigational & Not Medically Necessary statement on radiofrequency ablation using a transcervical approach

 

Medical Policies

On August 12, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire). These guidelines take effect December 8, 2021.

 

Publish date	Medical Policy #	Medical Policy title	New or revised
10/6/2021	*DME.00043	Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring	New
10/6/2021	*GENE.00058	TruGraf Blood Gene Expression Test for Transplant Monitoring	New
10/6/2021	*LAB.00040	Serum Biomarker Tests for Risk of Preeclampsia	New
10/6/2021	*LAB.00042	Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy	New
10/6/2021	*OR-PR.00007	Microprocessor Controlled Knee-Ankle-Foot Orthosis	New
8/19/2021	*SURG.00032	Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention	Revised
8/19/2021	*SURG.00077	Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques	Revised
8/19/2021	SURG.00119	Endobronchial Valve Devices	Revised
8/19/2021	SURG.00121	Transcatheter Heart Valve Procedures	Revised

 

Clinical UM Guidelines

On August 12, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines were adopted by the medical operations committee for members on September 23, 2021. These guidelines take effect December 8, 2021.

 

Publish date	Clinical UM Guideline #	Clinical UM Guideline title	New or revised
10/6/2021	*CG-SURG-112	Carpal Tunnel Decompression Surgery	New
10/6/2021	*CG-SURG-113	Tonsillectomy with or without Adenoidectomy for Adults	New
10/6/2021	CG-DME-44	Electric Tumor Treatment Field (TTF)	Revised
8/19/2021	CG-GENE-22	Gene Expression Profiling for Managing Breast Cancer Treatment	Revised
8/19/2021	CG-MED-55	Site of Care: Advanced Radiologic Imaging	Revised
8/19/2021	CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids	Revised

 

NYE-NU-0378-21 October 2021

 

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

 

Below are images reflecting the scenarios that have been enhanced:

Paper remittance

 

 

Electronic remittance advice (ERA/835)

 

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:

• Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
• Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

 

2. Searching for non-payment remittance:

• Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
• Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

 

The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire.

 

NYE-NU-0350-21 October 2021                                                                                                                

 

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

Empire is transitioning to Availity* Authorization

You may already be familiar with the Availity Authorization App because thousands of providers are already using it for submitting prior authorization requests for other payers. Empire is eager to make it available to our providers, too. On December 1  3, 2021, you can begin using the same authorization app you may use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Empire.

 

Current prior authorization tool (ICR) is still available

If you need to refer to an authorization that was previously submitted through the Interactive Care Reviewer (ICR) tool, you will still have access to that information. We’ve developed a pathway for you to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization App.

 

Innovation in progress

While we grow the Availity Authorization App to provide you with Empire-specific information, we’ve provided access to ICR for:

• Behavioral health authorizations.
• FEP authorizations.
• Clinician administered drugs.

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

 

Training is available

If you aren’t already familiar with the Availity Authorization App, training is available.

You can always log onto https://availity.com and view the webinar at your convenience. From Help & Training, select Get Trained to access the Availity Learning Center. You can use AvAuthRef for a keyword search or select the Session tab to see all upcoming live webinars.

 

Now, give it a try!

Accessing the Availity Authorization App is easy. Just log onto https://availity.com, and the Authorizations and Referrals icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

 

If you have questions, please reach out to Availity at 800-282-4548.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire.

 

NYE-NU-0374-21 October 2021

519305MUPENMUB

 

Please continue to check Medicaid Provider Communications & Updates at www.empireblue.com/nymedicaiddoc for the latest Medicaid information including:

• Durable medical equipment prior authorization requirement changes effective December 1, 2021
• Cancer Care Navigator
• Medical drug benefit Clinical Criteria updates
• Prior authorization updates for medications billed under the medical
  benefit
• Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines
• Updates to AIM Specialty Health musculoskeletal interventional pain management
  clinical appropriateness guideline

 

Anticipated to begin in Q1 2022, The City of New York Retirees (GRS) transition to an integrated Medicare Advantage PPO plan via an Empire BlueCross BlueShield (Empire) and EmblemHealth (the ‘Alliance’), which follows Medicare rules and is a national program. The Alliance program provides comprehensive health coverage to retirees, inclusive of all benefits provided by original Medicare, plus additional benefits. The Alliance plan name is NYC Medicare Advantage Plus and is easily identified as plan members have one insurance card displaying an alpha prefix of N6Y and a unique Medicare Advantage PPO suitcase logo.

 

Empire and EmblemHealth network arrangement is applicable in the following 13 downstate New York counties: New York, Bronx, Kings, Queens, Richmond, Nassau, Suffolk, Westchester, Orange, Rockland, Putnam, Dutchess, and Sullivan. Medicare Advantage PPO professional and facility providers outside of the counties listed above will be considered participating. NYC Medicare Advantage Plus members have access to Medicare Advantage PPO providers contracted with Blue Cross Blue Shield Association plans across the nation.

 

Members do not need referrals for any providers, specialists, or hospitals in or out of the network. Actual benefit payments are subject to eligibility and coverage limitations at the time services are rendered. Claims should be submitted electronically using payer ID CONY1 or paper submission (via UB-04 or CMS-1500 form) to Empire (the local Blue plan).

 

The following grid illustrates which insurer has claims rate responsibility for NYC Medicare Advantage Plus plan benefits. Notably, all claims for NYC Medicare Advantage Plus plan members must be submitted to Empire (the local Blue plan) for both the hospital (facility) and medical (professional) benefits, regardless of services rendered or health plan claims rate responsibility, to ensure a seamless claims process and experience for providers and facilities alike. 

 

Under no circumstances should claims be submitted directly to EmblemHealth for NYC Medicare Advantage Plus plan members.

 

Empire (the local Blue plan) will process and adjudicate all claims for NYC Medicare Advantage Plus plan benefits.

 

Empire rate applies to facility-based services, including but not limited to those listed below, in all geographies, including within the 13 downstate New York counties. All claims must be submitted to Empire (the local Blue plan):
•       Acupuncture •       Air/ground ambulance •       Ambulatory infusions •       Audiology (hearing aids) •       Behavioral health (professional/facility) •       Dialysis •       Diabetic supplies •       Durable medical equipment •       Emergency care •       Facility hospitals	•       Home health •       Home infusion therapy •       Nutrition (registered dietitians) •       Orthotics and prosthetics •       Pathology •       Pharmacy (Part B drugs covered under medical plan) •       Private duty nursing •       Reference labs •       Skilled nursing facilities (SNFs) •       Urgent care
EmblemHealth rate applies to directly contracted professional/traditional services, including but not limited to those listed below, only within the 13 downstate New York counties. All claims must be submitted to Empire (the local Blue plan):
•       Professional and specialist providers •       Chiropractic	•       Occupational therapy •       Physical therapy •       Speech therapy

EBSCARE-0706-21 October 2021

 

We are offering webinars to help you understand the upcoming changes for City of New York retirees transitioning to the Medicare Advantage Plus plan from Empire BlueCross BlueShield, anticipated to begin in Q1 2022. The webinars will review key operational processes such as determining eligibility and benefits, prior authorization requirements, and claims submissions to assist you in continuing to provide care for City of New York retirees. Please access the following invitation link to register for a webinar during the months of November, December, and January: https://empireblue.com/da/inline/pdf/ebscare-1086-21.pdf.

 

EMBCARE-0017-21

 

Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT^® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override. 

 

For additional information, please review the Drug Screen Testing reimbursement policy at https://www.empireblue.com/medicareprovider.

 

EBSCRNU-0198-21 October 2021

Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health_® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Updates by guideline:

• Imaging of the Brain:

• Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
• Meningioma — new guideline establishing follow-up intervals
• Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
• Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

• Imaging of the Head and Neck:
  • Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
  • Temporomandibular joint dysfunction — specified duration of required conservative management
• Imaging of the Heart:
  • Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
• Imaging of the Chest:
  • Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
  • Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
• Imaging of the Abdomen and Pelvis:
  • Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
  • Intussusception — removed as a standalone indication
  • Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
  • Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
  • Azotemia — removed as a standalone indication
  • Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline

• Diffuse liver disease – new indication for multiparametric MRI for fibrosis and hemochromatosis

• Oncologic Imaging:
  • National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and Non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
  • Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
  • Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

 
As a reminder, ordering and servicing providers may siubmit prior authorization requests to AIM via:

• AIM’s ProviderPortal_SM 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.
• The Availity* Portal at availity.com.
• Phone at 855-574-6481, Monday through Friday from 8 a.m. to 8 p.m. ET.

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield HealthPlus. Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0377-21 October 2021

 

An overview of notable 2022 benefit changes and service area updates are now available here. Please continue to check https://www.empireblue.com/medicareprovider for the latest Medicare Advantage information.

 

EBSCRNU-0209-21 October 2021

Beginning January 1, 2022, Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans (MMPs) are responsible for adjudicating claims for COVID-19 vaccines and their administration and for
COVID-19 monoclonal antibodies and their administration.

 

EBSCRNU-0210-21 October 2021

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

 

Below are images reflecting the scenarios that have been enhanced:

Paper remittance

 

 

Electronic remittance advice (ERA/835)

 

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:

• Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
• Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

 

2. Searching for non-payment remittance:

• Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
• Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

 

The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire.

 

NYE-NU-0350-21 October 2021                                                                                                                

 

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

Empire is transitioning to Availity* Authorization

You may already be familiar with the Availity Authorization App because thousands of providers are already using it for submitting prior authorization requests for other payers. Empire is eager to make it available to our providers, too. On December 1  3, 2021, you can begin using the same authorization app you may use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Empire.

 

Current prior authorization tool (ICR) is still available

If you need to refer to an authorization that was previously submitted through the Interactive Care Reviewer (ICR) tool, you will still have access to that information. We’ve developed a pathway for you to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization App.

 

Innovation in progress

While we grow the Availity Authorization App to provide you with Empire-specific information, we’ve provided access to ICR for:

• Behavioral health authorizations.
• FEP authorizations.
• Clinician administered drugs.

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

 

Training is available

If you aren’t already familiar with the Availity Authorization App, training is available.

You can always log onto https://availity.com and view the webinar at your convenience. From Help & Training, select Get Trained to access the Availity Learning Center. You can use AvAuthRef for a keyword search or select the Session tab to see all upcoming live webinars.

 

Now, give it a try!

Accessing the Availity Authorization App is easy. Just log onto https://availity.com, and the Authorizations and Referrals icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

 

If you have questions, please reach out to Availity at 800-282-4548.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire.

 

NYE-NU-0374-21 October 2021

519305MUPENMUB

 

Please continue to read news and updates at empireblue.com/medicareprovider for the latest Medicare Advantage information, including:

• Medical drug benefit Clinical Criteria updates
• FAQ: NYC Medicare Advantage Plus
• Protocol for out-of-network providers serving members with hearing aid
  coverage administered by Hearing Care Solutions
• Medical Policies and Clinical Utilization Management Guidelines update
• Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines
• Updates to AIM Specialty Health musculoskeletal interventional pain management
  clinical appropriateness guideline