 Provider News New YorkFebruary 2019 Empire Provider NewsletterBeginning 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 at empireblue.com/provider/ > “Find Resources in New York” > Provider Home > Health and Wellness > Practice Guidelines. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning in May 2019, Empire will enhance its’ claims editing systems to include outpatient facility editing.
These edits will:
- help ensure correct coding and billing practices are being followed
- help ensure compliance with industry standards such as American Medical Association (AMA), National Uniform Billing Committee (NUBC), and national specialty and academy guidelines
- reinforce compliance with standard code edits and rules (i.e., CPT, HCPCS, ICD-10, NUBC)
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 May 18, 2019, the following updates will apply to the AIM Specialty Health Musculoskeletal Program Clinical Appropriateness Guidelines.
Spine Surgery - Enhancements as indicated by section below:
-Reporting of symptom severity: expanded to include IADLs as functional impairment
-Tobacco Cessation: removed nicotine-free documentation requirement
- Cervical Decompression with or without Fusion
-Added exclusion of cervical/thoracic laminectomy if criteria not met
- Lumbar Discectomy, Foraminotomy, and Laminotomy
-Added criteria to define radicular pain for Lumbar herniated intervertebral disc
- Lumbar Fusion and Treatment of Spinal Deformity (including scoliosis and Kyphosis)
-Added indication and criteria for Flat back Deformity
-Added criteria for Isthmic spondylolisthesis
-Added indication and criteria for Scheuermann’s Kyphosis
-Added exclusion of lumbar laminectomy if criteria not met
- Noninvasive Electrical Bone Growth Stimulation
-Added risk factor criteria for cervical non-invasive bone growth stimulation
Interventional Pain Guidelines - Enhancements as indicated by section below:
-Reporting of symptom severity: expanded to include IADLs as functional impairment
- Therapeutic Epidural Steroid Injection
-Updated time period of initial advanced imaging
-Definition and frequency of repeat therapeutic epidural steroid injection
-Updated maximum number of annual injections
-Added criteria for subsequent injection after suboptimal initial response
- Paravertebral Facet Injection/Nerve Block/Neurolysis
-Updated injection frequency limitations
- Diagnostic Intraarticular Sacroiliac Joint Injections
-Updated pain reduction from initial injection
-Added criteria for revision/removal of spinal cord stimulator
-Separated criteria of trial stimulation and permanent stimulator implantation
-Added exclusion of dorsal root ganglion stimulation
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortallSM 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.
Please note, this program does not apply to FEP or National Accounts.
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 guidelines here. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (The following guidelines are no longer adopted.)
- CG-SURG-18-Septoplasty
- CG-SURG-30-Tonsillectomy for Children with or without Adenoidectomy
- CG-MED-46-Electroencephalography and Video Electroencephalographic Monitoring
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (The following guidelines were previously not adopted and have now been adopted. No significant changes were made.)
- CG-SURG-49 – Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM Coding Guidelines, when selecting the most appropriate diagnosis for patient encounters. Remember ICD-10-CM has two different types of excludes notes and each type has a different definition. In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes. An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after May 1, 2019, Empire is updating the facility Body Mass Index (BMI) Reimbursement Policy. Reimbursement will be based on a review of all comorbidities, diagnosis codes reported, and the facility specific reimbursement methodology for Body Mass Index (BMI) diagnosis codes reported as a secondary clinical condition along with other criteria set forth in our policy.
You may review our updated policy dated May 1, 2019 by visiting the by visiting 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. Beginning with dates of service on or after May 1, 2019, Empire is updating our Injectable Substances with Related Injection Services reimbursement policy. The update will reflect that when a claim for an injection service is submitted without the applicable Healthcare Common Procedure Coding System (HCPCS Level II) drug or injectable substance code for the injected drug or substance, the code for the injection service will not be eligible for reimbursement.
Additionally, when submitting a claim for an aspiration service, with our without an injection, J3590 (unclassified biologics) with a zero charge to indicate the biologic contents of the syringe after aspiration must be included on the claim or it will not be eligible for reimbursement.
For additional information, review our updated policy dated May 1, 2019 by visiting the by visiting 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. Centauri Health Solutions is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers, and ask that you respond to the requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe. Centauri Health will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary). We ask that you please promptly comply within five (5) business days of the record requests. If you have any questions, please contact Catherine Carmichael with Blue Cross Blue Shield Federal Employee Program at (202) 942-1173 or Carol Oravec with Centauri at (440) 793-7727. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The following clinical criteria will be effective May 1, 2019.
Colony Stimulating Factor Agents ING-CC-0002
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.
Empire’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Additional information regarding biosimilar drugs can be found by viewing the attached reference document, “Biosimilar Drugs – What are they?”
To access the clinical criteria information please click here.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS
or
CPT Code
|
NDC Code
|
|
ING-CC-0002
|
Preferred Agent
|
Zarxio®
|
Q5101
|
61314-0304-01
61314-0304-10
61314-0312-01
61314-0312-10
61314-0318-01
61314-0318-10
61314-0326-01
61314-0326-10
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Neupogen®
|
J1442
|
55513-0530-01
55513-0530-10
55513-0546-01
55513-0546-10
55513-0924-01
55513-0924-10
55513-0924-91
55513-0209-01
55513-0209-10
55513-0209-91
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Granix®
|
J1447
|
63459-0910-11
63459-0910-12
63459-0910-15
63459-0910-17
63459-0910-36
63459-0912-11
63459-0912-12
63459-0912-15
63459-0912-17
63459-0912-36
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Nivestym™
|
Q5110
|
00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
|
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 list s are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.”
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
AllianceRX Walgreens Prime is the specialty pharmacy program for the Federal Employee Program. You can view the Specialty Drug List or call us at 1-888-346-3731 for more information. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The following clinical criteria will be effective May 1, 2019.
Erythropoiesis Stimulating Agents ING-CC-0001
Clinical criteria ING-CC-0001 addresses the use of recombinant erythropoietin products, also known as erythropoiesis stimulating agents (ESAs), for the treatment of severe anemia in chronic kidney disease (CKD), HIV, cancer, surgery, and other conditions.
Effective for dates of service on and after May 1, 2019, the use of Procrit®, Epogen®, and Retacrit™ for the treatment of severe anemia in hepatitis C, chronic inflammatory disease, and bone marrow transplant are considered not medically necessary.
H.P. Acthar Gel® (repository corticotropin injection) ING-CC-0004
Clinical criteria ING-CC-0004 addresses the use of repository corticotropin injection for the treatment of infantile spasms (West syndrome) and adults with a corticosteroid-responsive condition, including but not limited to acute exacerbations of multiple sclerosis.
Effective for dates of service on and after May 1, 2019, repository corticotropin injections for the treatment of conditions other than infantile spasms (West syndrome) are considered not medically necessary.
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists ING-CC-0072
Clinical criteria ING-CC-0072 addresses the use of intravitreal vascular endothelial growth factor (VEGF) antagonists for the treatment of diabetic retinopathy and other retinal disorders associated with neovascularization.
Effective for dates of service on and after May 1, 2019, the use of Eylea® for the treatment of radiation retinopathy is considered not medically necessary.
To access the clinical criteria information please click 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 May 1, 2019, the following specialty pharmacy codes from new clinical criteria or current clinical guideline will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
Empire’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
The following clinical criteria will be effective May 1, 2019.
|
Clinical Criteria/Guideline
|
HCPCS or CPT Code
|
NDC Code
|
Drug
|
|
CG-DRUG-63
|
J3490
|
68152-0112-01
68152-0114-01
|
Khapzory™
|
|
ING-CC-0002
|
Q5110
|
00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
|
Nivestym™
|
|
ING-CC-0002
|
J3490
|
68152-0112-01
68152-0114-01
|
Udenyca™
|
|
ING-CC-0003
|
J1599
|
68982-0820-01
68982-0820-02
68982-0820-03
68982-0820-04
68982-0820-05
68982-0820-06
68982-0820-81
68982-0820-82
68982-0820-83
68982-0820-84
68982-0820-85
68982-0820-86
|
Panzyga®
|
|
ING-CC-0034
|
J3590
|
47783-0644-01
|
Takhzyro®
|
|
ING-CC-0062
|
J3590
|
61314-0871-02
61314-0871-06
61314-0876-02
|
Hyrimoz™
|
|
ING-CC-0062
|
Q5109
|
00069-0811-01
|
Ixifi™
|
|
ING-CC-0065
|
J7192
|
00026-3942-25
00026-3944-25
00026-3946-25
00026-3948-25
00026-4942-01
00026-4944-01
00026-4946-01
00026-4948-01
|
Jivi®
|
|
ING-CC-0074
|
J8655
|
69639-0102-01
|
Akynzeo®
|
|
ING-CC-0077
|
C9399
J3590
|
68135-0058-90
68135-0673-40
68135-0673-45
68135-0756-20
|
Palynziq™
|
|
ING-CC-0081
|
J0584
|
69794-0102-01
69794-0203-01
69794-0304-01
|
Crysvita®
|
|
ING-CC-0082
|
C9399
J3490
|
71336-1000-01
|
Onpattro™
|
To access the clinical criteria information please click here. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In ICD-10-CM, diabetes is classified in categories E8 through E13. The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected and the complications affecting the body system. To read more about diabetes coding, please view the attached full article. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (Policy 06-003, effective 05/01/2019)
The Empire BlueCross BlueShield HealthPlus (Empire) Modifier 25 reimbursement policy provides the criteria for reimbursement for a significant, separately identifiable evaluation and management (E&M) service performed by the same provider on the same day of the original service or procedure. Effective May 1, 2019, Empire does not allow separate reimbursement for E&Ms performed on the same day as a major surgery (90-day global period).
For additional information, refer to the Modifier 25 reimbursement policy at www.empireblue.com/nymedicaiddoc. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.
This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.
Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.
If you have questions or feedback, please use this email link. 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 May 1, 2019, the specialty pharmacy drugs and corresponding codes from current clinical criteria noted below will be included in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review (as is done currently).
The clinical criteria below have been updated to include the requirement of a preferred agent effective May 1, 2019.
|
Clinical criteria
|
Preferred drug
|
Nonpreferred drug
|
|
ING-CC-0001
|
Retacrit (Q5106)
|
Procrit (J0885)
|
|
ING-CC-0002
|
Zarxio (Q5101)
|
Neupogen (J1442), Granix (J1447) and Nivestym (Q5110)
|
The clinical criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific clinical criteria.
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. Effective for dates of service beginning January 1, 2019, the following Medicare Part B devices will be preferred to support cost-effective benefits. During precertification initiation or renewal, providers requesting a nonpreferred device will be encouraged to switch to a preferred product. The preferred and nonpreferred products are listed below.
Preferred Devices
- Euflexxa® (J7323)
- Hyalgan® /Supartz® (J7321)
- Duralone® (J7318)
Non-preferred Devices
- Gel-One® (J7326)
- Gelsyn-3® (J7328)
- Genvisc 850® (J7320)
- Hymovis® (J7322)
- MonoviscTM (J7327)
- Orthovisc® (J7324)
- Syncvisc® or Synvisc-One® (J7325)
- TrivuscTM (J7329)
75557MUSENMUB 12/20/18Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Refractions and routine eye exams are not covered under medical insurance for Empire members. These benefits may be available through the member’s supplemental insurance. These services must be billed to the supplemental vendor. Check your patient’s Empire ID card for the name of the vendor.
Additional information, including billing modifiers and documentation requirements, will be available at empireblue.com/medicareprovider under Important Medicare Advantage Updates. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. AIM Specialty Health® groups CPT codes on authorizations so they can be reviewed together to support a procedure or therapy. Grouped codes are used for radiology, cardiology, and sleep and radiation therapy programs. The groupings can be found at http://aimspecialtyhealth.com/ClinicalGuidelines.html by selecting the appropriate solution and then the exam or therapy being performed. Additional information is available at empireblue.com/medicareprovider under Important Medicare Advantage Updates. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire is required to follow all clinical and reimbursement policies established by Original Medicare in the processing of claims and determining benefits. Empire follows all Original Medicare local coverage determinations, national coverage determinations, Medicare rulings, code editing logic and the Social Security Act.
Empire may offer additional benefits that are not covered under Original Medicare. Certain benefits are only covered when provided by a vendor selected by Empire. More information can be found at empireblue.com/medicareprovider. You may also contact Provider Services at the phone number on the back of the member ID card. |