 Provider News New YorkFebruary 2021 Empire Provider NewsBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.
Visit empireblue.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Find Care, the doctor finder and transparency tool in Empire BlueCross BlueShield’s (“Empire”) online directory, provides many Empire members with the ability to search and compare cost and quality measures for in-network providers using the secure member portal at empireblue.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, name, or personalized match.
Beginning March 13, 2021, the personalized match sorting option will be available for searches by procedure type. This sorting option is based on algorithms which will use a combination of member and provider features to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions and demographics. Provider factors such as surgeon-facility pairing (an individual provider who performs a procedure at a specific facility), cost efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.
These member and provider features will be combined to generate a unique ranking of surgeon-facility pairings or facility providers for each member conducting the procedure search. Surgeon-facility pairings with the highest overall ranking within the search radius will be displayed first with other pairings displayed in descending order based on overall rank and proximity to the center of the search radius.
The personalized match methodology for specialty-based searches remains unchanged. Members continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology has no impact on member benefits.
- Providers may review a copy of the new sorting methodology which has been posted on Availity – our secure Web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Empire > Education & Reference Center > Administrative Support > Personalized Provider Procedure Search Methodology.pdf.
- If you have general questions about the Find Care tool or this new sorting option, please contact Provider Customer Service.
- If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors, you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.
Going forward, Empire will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. A new facility reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services will be implemented beginning with dates of service on, or after May 1, 2021. Empire BlueCross BlueShield (“Empire”) does not allow reimbursement for office evaluation and management services when reported on a CMS 1450 (UB-04) with revenue code 761 (treatment rooms). Modifiers will not override the edit.
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. A new facility reimbursement policy titled Emergency Room Transfers will be implemented beginning with dates of service on, or after May 1, 2021. The policy allows reimbursement for one emergency room visit when a patient is transferred between facilities operating under the same agreement, have the same tax identification number (TIN), or is under common ownership. The transferring facility will not be eligible for separate reimbursement.
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. Prior authorization updates
Effective for dates of service on and after May 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.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0183
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J3590
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Sogroya
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*ING-CC-0001
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J0886
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Injection, epoetin alfa (Procrit/Epogen)
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*ING-CC-0019
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J3489
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Reclast, Zometa
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Quantity Limit Updates
Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit 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’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.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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|
*ING-CC-0019
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J3489
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Reclast, Zometa
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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. Effective with dates of service on and after April 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Empire BlueCross BlueShield (“Empire”) will update its drug lists that support commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We are committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.
Effective August 1, 2021, AIM Specialty Health® (AIM),* a separate company, will expand the AIM Rehabilitative program to perform medical necessity review evaluations for physical, occupational and speech therapy procedures and the requested site of care for Empire BlueCross Blue Shield HealthPlus (Empire) fully insured members, as further outlined below.
AIM will continue to manage physical therapy (PT), occupational therapy (OT) and speech therapy (ST) medical necessity reviews and will require prior authorization for all outpatient facility and office-based rehabilitative and habilitative services. Prior authorization will now also be required for the initial evaluation and the requested site of care. AIM will use the following Empire Clinical UM Guidelines: CG.REHAB.10 Level of care: outpatient physical therapy, occupational therapy and speech-language pathology services. This clinical guideline can be reviewed online at https://www.availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, services with diagnosis of autism, or the initial evaluation.
A complete list of CPT® codes requiring prior authorization for the AIM Rehabilitation program is available on the AIM Rehabilitation microsite. To determine if prior authorization is needed for an Empire member on or after August 1, 2021, providers can contact Provider Services at 1-800-450-8753 for benefit information. They will be informed whether the AIM Rehabilitation program applies. AIM will also have a file upload from the health plan of the in-scope membership and will not provide pre-certification for members who are out of scope. If providers use the interactive care reviewer (ICR) tool on the Availity Portal* to pre-certify an outpatient rehabilitative or habilitative service, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests.)
AIM will be accepting authorizations on July 19, 2021, for services performed on or after August 1, 2021.
How to place a review request
Providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortallSM directly at http://www.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 https://www.availity.com.
- Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. ET.
Initiating a request on AIM’s ProviderPortalSM for PT/OT/ST and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the order ID, the number of visits and valid time frame. The AIM Rehabilitation Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM Rehabilitation training webinars:
Empire invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to the AIM Rehabilitation microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.
We value your participation in our network and look forward to working with you to help improve the health of our members.
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. On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
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. New: additional benefit detail
Now, you can select Additional Benefit Notes, on the Availity Portal* Eligibility and Benefits results screen to find more descriptive benefit information.
Benefits are listed in alphabetical order, making it easier to search for specific benefits. Capabilities include full benefit descriptions, vendor information associated with the benefit and the option for the provider to print out the benefit information.
Digital member ID cards
The digital member ID card allows easy, low-touch access to view additional information or confirm basic membership details.
When conducting an eligibility and benefits inquiry for our members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: The Availity Portal requires you to enter the member’s ID number, as well as a date of birth or the member’s first and last name into the search options in order to submit an eligibility and benefits inquiry.
Try both of these valuable tools today!
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Revised measures:
- The former Well-Child Visits in the First 15 Months of Life (W15) measure was revised to Well‑Child Visits in the First 30 Months of Life (W30). It includes two indicators:
- Well-child visits in the first 15 months — children who turned 15 months during the measurement year with six or more well-child visits
- Well-child visits for ages 15 to 30 months — children who turn 30 months during the measurement year with two or more well-child visits
- The former Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) and Adolescent Well-Care Visits (AWC) measures have been combined into Child and Adolescent Well-Care Visits (WCV):
- The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year
Key measure changes:
- Controlling High Blood Pressure (CBP and CDC-CBP)
Telephone visits, e-visits and virtual check-ins are now acceptable settings for blood pressure (BP) readings. Digital BP readings reported by the member are considered numerator compliant.
- Telehealth updates
NCQA has updated telehealth guidance in 40 HEDIS® measures for HEDIS measurement years 2020 and 2021. The purpose of these changes is to:
- Support increased use of telehealth caused by the pandemic.
- Align with guidance from Centers for Medicare & Medicaid Services and other stakeholders.
A list of the 40 measures can be found on the NCQA COVID-19 website at www.ncqa.org/covid.
New Medicaid measures:
Kidney Health Evaluation for Patients With Diabetes (KED) — The percentage of members 18 to 85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a uACR identified by both a quantitative urine albumin test and a urine creatinine test with service days four or less days apart during the measurement year
Cardiac Rehabilitation (CRE) — The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation, or heart valve repair/replacement; four rates are reported:
- Initiation — The percentage of members who attended two or more sessions of cardiac rehabilitation within 30 days after a qualifying event
- Engagement 1 — The percentage of members who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event
- Engagement 2 — The percentage of members who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
- Achievement — The percentage of members who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
Retired Medicaid measures:
- Comprehensive Diabetes Care (CDC) retired sub-measures —
- Medical Attention for Nephropathy (retired for Commercial and Medicaid)
- HbA1c control (< 7.0%) for a selected population
- Adult BMI Assessment (ABA)
- Medication Management for People With Asthma (MMA)
- Children’s and Adolescents’ Access to Primary Care Practitioners (CAP)
Measure change summary:
For a complete summary, go to https://tinyurl.com/NCQA-measures.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. CAHPS is an annual standardized survey conducted from January to May to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may get the survey. Providers directly impact the majority of questions used for scoring.
These questions are:
- When you needed care right way, how often did you get it?
- How often did you get an appointment for a check-up or routine care as soon as you needed it?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed it?
- How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
- How would you rate your primary care doctor?
- How would you rate the specialist you see most often?
To learn more about CAHPS and how you can improve the patient experience, review the CAHPS Overview training by visiting www.empireblue.com/nymedicaiddoc.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This HEDIS ® measure evaluates the percentage of members’ age 50 to 75 who had appropriate screening for colorectal cancer.
Record your efforts
Document (date and result) one or more of these screenings:
- Colonoscopy during measurement year or nine years prior
- Fecal occult blood test (FOBT) during measurement year
- CT colonography during measurement year or four years prior
- Fecal immunochemical test (FIT)-DNA test during measurement year or two years prior
- Flexible sigmoidoscopy during measurement year or four years prior
Exclusions:
- Diagnosis of colorectal cancer
- Total colectomy
- Members who receive palliative care
Need help getting your patients screened for colorectal cancer?
As an option, participating providers can order FIT kits through Quest Diagnostics.®* Quest will ship InSure® ONE™ FIT kits directly to your practice. To order:
- Online, use the Quest Quanum® Lab Services Manager. Create an account at https://bit.ly/3qLxNPh.
- Via phone, call 1-866-MY-QUEST and state supplies for assistance.
Quest will ship the kits to your practice at no cost, based on usage and test completion.
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 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation or renewal, in addition to the current medical necessity review of all drugs noted below.
Below are the Clinical Criteria that have been updated to include the requirement of a preferred agent effective March 1, 2021.
The Clinical Criteria are made publicly available on the Empire BlueCross BlueShield HealthPlus provider website. Visit https://bit.ly/3quo9A5 to search for specific Clinical Criteria.
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Clinical Criteria
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Status
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Drug name
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HCPCS code
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ING-CC-0002
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Preferred
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Neulasta
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J2505
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ING-CC-0002
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Preferred
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Udenyca
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Q5111
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ING-CC-0002
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Non-preferred
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Fulphila
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Q5108
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|
ING-CC-0002
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Non-preferred
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Ziextenzo
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Q5120
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ING-CC-0002
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Non-preferred
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Nyvepria
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J3590
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective April 1, 2021, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Empire BlueCross BlueShield HealthPlus for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
PA requirements will be added to the following:
- 30117 — Excision/Destruction, Intranasal Lesion; Int Approach
- 30999 — Unlisted Proc, Nose
- 54401 — Insertion, Penile Prosthesis; Inflatable (Self-Contained)
- C1778 — Lead, neurostimulator (implantable)
- C1787 — Patient programmer, neurostimulator
- C2622 — Prosthesis, penile, noninflatable
- G0157 — Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes
- G2168 — Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes
- G2169 — Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes
- L8681 — Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
- L8699 — Prosthetic Implant Nos
To request PA, you may use one of the following methods:
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the Precertification Lookup Tool on the Availity* Portal at https://www.availity.com or on the provider website at http://www.empireblue.com/nymedicaiddoc. Contracted and noncontracted providers who are unable to access Availity, may call Provider Services at 1-800-450-8753 for assistance with PA requirements.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective March 1, 2021, prior authorization (PA) requirements will change for 55899. The Medical codes listed below will require PA by Empire BlueCross BlueShield HealthPlus. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
PA requirements will be added to the following:
- 55899 — Unlisted procedure, male genital system
To request PA, you may use one of the following methods:
Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com by visiting www.empireblue.com/nymedicaiddoc > Login. Contracted and noncontracted providers who are unable to access Availity* may call Provider Services at 1-800-450-8753 for PA requirements.
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