The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is:

• We’ll receive the documents needed faster than through the mail.
• Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
• Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
• More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.

However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays:

1. Valid claim number

or

2. Valid member ID with prefix and correct dates of service

or

3. Valid member ID with prefix and billed charges

For a clinical appeal, ensure these elements are included:

1. Valid claim number

or

2. Valid member ID with prefix and correct dates of service

or

3. Valid member ID with prefix) and billed charges

or

4. Member name, member date of birth, and correct dates of service

or

5. Member name, member date of birth, authorization, or reference number

This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission.

The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission.

To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation.

For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal.

If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation.

For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow.

We are committed to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year.

Stay tuned for more updates.

These updates list the new and/or revised Medical Policies and Clinical Guidelines for Empire BlueCross BlueShield (Empire). The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and Clinical Guidelines (and Medical Policy takes precedence over Clinical Guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the service is rendered must be used. This document supplements any previous Medical Policy and Clinical Guideline updates that may have been issued by Empire. Please include this update with your provider manual for future reference.

Please note that Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Empire’s Medical Policies and Clinical Guidelines can be found at https://www.empireblue.com.

Note: These updates may not apply to all administrative services only accounts as some accounts may have nonstandard benefits that apply.

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program [FEP^®]), visit www.fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policy effective May 1, 2023

The following policy is new:

• MED.00143 Ingestible Devices for the Treatment of Constipation

Revised Medical Policies effective May 1, 2023

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• MED.00130 Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring
• SURG.00097 Scoliosis Surgery

Clinical Guideline updates

Revised Clinical Guideline effective May 1, 2023

The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CG-DME-31 Powered Wheeled Mobility Devices

As previously communicated in the December 2022 edition of Provider News, AIM Specialty Health_® (AIM)* will apply additional code updates to the AIM Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. That code update expansion has been delayed. The codes listed below will go into effect April 1, 2023, not February 1, 2023, as originally communicated.

Percutaneous coronary intervention:

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access 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.
• Call the AIM Contact Center toll-free number at 800-714-0040, Monday through Friday, from 7 a.m. to 7 p.m. Central

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

The Empire BlueCross BlueShield (Empire) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by the Medical Specialty Drug Review team of Empire. Oncology drugs will be managed by AIM Specialty Health_® (AIM),* a separate company.

The following Clinical Criteria documents were endorsed at the November 18, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective May 1, 2023

The following Clinical Criteria are new:

• CC-0222 Tecvayli (teclistamab-cqyv)
• CC-0223 Imjudo (tremelimumab-actl)
• CC-0224 Pedmark (sodium thiosulfate injection)

Revised Clinical Criteria effective May 1, 2023

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CC-0003 Immunoglobulins
• CC-0041 Complement Inhibitors
• CC-0042 Monoclonal Antibodies to Interleukin-17
• CC-0050 Monoclonal Antibodies to Interleukin-23
• CC-0062 Tumor Necrosis Factor Antagonists
• CC-0063 Stelara (ustekinumab)
• CC-0064 Interleukin-1 Inhibitors
• CC-0066 Monoclonal Antibodies to Interleukin-6
• CC-0071 Entyvio (vedolizumab)
• CC-0078 Orencia (abatacept)
• CC-0100 Istodax (romidepsin)
• CC-0107 Bevacizumab for Non-Ophthalmologic Indications
• CC-0124 Keytruda (pembrolizumab)
• CC-0150 Kymriah (tisagenlecleucel)
• CC-0151 Yescarta (axicabtagene ciloleucel)
• CC-0168 Tecartus (brexucabtagene autoleucel)
• CC-0187 Breyanzi (lisocabtagene maraleucel)
• CC-0195 Abecma (idecabtagene vicleucel)
• CC-0204 Tivdak (tisotumab vedotin-tftv)
• CC-0205 Fyarro (siroliumus albumin bound)
• CC-0214 Carvykti (ciltacabtagene autoleucel)

Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by Empire BlueCross Blue Shield’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_®* (AIM), a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to submit a prior authorization for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing for drugs billed with a Not Otherwise Classified (NOC) code.

Reminder: Clinical Criteria name change

In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged.

Prior authorization updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

* Oncology use is managed by AIM.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Step therapy updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. 

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent.

* Oncology use is managed by AIM.

Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status.

Quantity limit updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.