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.

We will begin requesting medical records in February via a phone call to your office followed by a fax.

 

The fax will contain 1) a cover letter with contact information your office can use to contact us if there are any questions; 2) a member list, which includes the member and HEDIS measure(s) the member was selected for; and 3) an instruction sheet listing the details for each HEDIS measure.  As a reminder, under HIPAA, releasing PHI for HEDIS data collection is permitted and does not require patient consent or authorization.  HEDIS and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities 45 CFR 164.506(c) (4)]. For more information, visit www.hhs.gov/ocr/privacy.

 

HEDIS review is time sensitive, so please submit the requested medical records within five business days. 

 

To return the medical record documentation back to us in the recommended 5-day turnaround time, simply choose one of these options:

Upload to our secure portal.  This is quick and easy.  Logon to www.submitrecords.com, enter the password included with your HEDIS Member List and select the files to be uploaded.  Once uploaded you will receive a confirmation number to retain for your records.

OR 

Send a secure fax to 1-888-251-2985

OR

Mail to us via the US Postal Service to: 
Empire, Inc., 66 E. Wadsworth Park Drive, Suite 110H, Draper, UT  84020

 

Please contact your Provider Network Representative to let them know if you have a specific person in your organization that we should contact for HEDIS medical records.

 

Thank you in advance for your support of HEDIS.

 

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

Empire is committed to investing in primary care, rewarding coordinated, patient-centered care, and promoting proactive chronic care management. In recognition of the time-intensive nature of this work, Empire will reimburse chronic care management and advance care planning services for Commercial health plans effective for claims processed on or after February 23, 2019.

 

Chronic care management (CCM) is care rendered by a physician or non‐physician health care provider and their clinical staff, once per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only one practitioner can bill a CCM service per service period (month). Three CCM codes are included in this payment policy change:  99490, 99487and 99489.

 

Advance care planning (ACP) is a face-to-face service between a physician or other qualified health care professional and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time.  No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary. Two ACP codes are included in the payment policy change: 99497 and 99498

 

Empire requires patient consent prior to CCM or ACP service(s) being provided. Please refer to the current Claims Requiring Additional Documentation policy for more information. 

 

For more information, review our Bundled Services and Supplies policy dated February 23, 2019  by visiting the Reimbursement Policies page at empireblue.com/provider. 

In early 2018, Empire became one of the first major insurers to reimburse EMS providers for appropriate and medically necessary care billed under HCPCS code A0998 (Ambulance response and treatment, no transport). The code, which has been active since January 2018 for most standard Empire benefit plans, allows EMS providers to receive reimbursement for treatment rendered in response to an emergency call to a member’s home or scene, when transportation to the hospital emergency room (ER) was not provided. Previously, Empire reimbursed EMS providers for treatment rendered only when a patient was transported to the ER.

 

Important reminders:

• The code is currently active and available for EMS use.
• If an EMS provider responds to an emergency call and provides appropriate treatment at-home or on-site without transporting to the ER, code A0998 can be used.
• The EMS provider must render treatment to the patient per EMS protocols which are approved by the medical director at the local or state level.
• Billing of A0998 when treatment is not rendered is not appropriate.
• Empire will apply medical necessity review to A0998 using coverage guideline CG-ANC-06.
• HCPCS code A0998 applies to all of Empire’s commercial health plans, and reimbursement will be made in accordance with the member’s benefits.

 

Questions?

• For contract questions, please reach out to your contract representative.

Has your office received a request for additional information to process a claim for a commercial Empire member? Those records can be submitted electronically using the Medical Attachments feature in your Availity claims processing portal.

 

The Medical Attachments feature makes submitting electronic documentation in support of a claim simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Empire) medical record attachments through the Availity Portal.

 

How to Access solicited Medical Attachments for Your Office

 

Availity Admin, complete these steps:

 

From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:

1. Select Application>choose Medical Attachments Registration
2. Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs Multiples can be added separated by spaces or semi-colons
3. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name

 

Using Medical Attachments

Availity User, complete these steps:

1. Log in to www.availity.com
2. Select Claims and Payments > Medical Attachments >Send Attachment Tab
3. Complete all required fields of the form
4. Attach supporting documentation
5. Submit

               

Need Training?

To access additional training for this Availity feature:

1. Log in to the Availity Portal at www.availity.com
2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
3. In the new window a list of available topics will open. Locate and click Medical Attachments
4. Under the Recordings section, click View Recording

 

Need More Information?

For more information, contact your provider relations representative.

Empire is now targeting January 9, 2019 to retire the Empire Facility and Physician Online Services. The retirement will be happening a few days earlier than what was announced in our December newsletter.

 

All information formerly on the Empire secure portals will be available exclusively through the Availity Portal (www.availity.com). 

 

Your preparations for this transition are vital and should include the following:

• If you are an administrator for your organization's Availity account:  Continue to use My Account Dashboard from the Availity home page to register new users and update or unlock accounts for existing users. Make sure all of your users have the roles they need to ensure a smooth transition.
• If you are a user today who regularly accesses information on both Empire Facility or Physician  Online Services and Availity: In these final days before the retirement of the Empire Portals, make sure you are able to access everything you require to perform your job duties off of the Availity Portal and work with your administrator to update your access if needed. To determine who your administrator is select My Administrators from your Availity Account Dashboard.
• If your organization is not registered for Availity:

Visit https://www.availity.com/ and select REGISTER to get started.  Want more information before starting your registration? Watch this video: Learn how to register your organization with Availity – Training Demo.

 

Finally, users now have two places to obtain valuable training tools and information.  If you would like more information on navigating in Availity, select Help & Training | My Learning Plan from the top navigation menu on the Availity home page to plot your learning journey.  Availity also offers onboarding modules for new administrators and users. To locate these modules select Help & Training | Get Trained to navigate to the Availity Learning Center, then type “onboarding” in the search field.

 

To find presentations and reference guides that can be used to educate you and your staff on Empire proprietary tools, select Payer Spaces| Applications| Education and Reference Center | Education and Communications. Or contact your Network Mangement Consultant.

Effective April 1, 2019, Empire will update its HMO, EPO, PPO, Small Group, Individual and Indemnity fee schedules.  

 

Although this update will result in an overall net increase of our physician network fees, the actual impact to any particular physician will depend on the codes most frequently billed by that physician.The complete updated fee schedule will be available on Availity.com upon their effective date of April 1, 2019.

These updates list the new and/or revised Empire medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy 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 services are 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 empireblue.com.

 

*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.

Empire BlueCross BlueShield HealthPlus invites you to take advantage of a free informational webinar that will introduce you to the robust capabilities of the AIM Specialty Health ProviderPortal®.

 

Learn how to submit your request online

The ProviderPortal is your access point for conveniently submitting order requests online. It allows you to open a new order, update an existing order and retrieve your order summary. As an online application, ProviderPortal is available 24 hours a day, 7 days a week. Your first step is to register your practice in ProviderPortal, if you are not already registered. Go to www.providerportal.com to register. If you have previously registered for other services managed by AIM, there is no need to register again.

 

Learning objectives In each session, you will have the opportunity to:

• See an overview of ProviderPortal, an online tool used to request AIM clinical review.
• Learn how to create and submit an order request, update an existing one, and retrieve your order summary.
• Get tips and shortcuts to navigate the system.
• See how to check the status of your requests.

 

Dates and times

• Thursday, January 24, 2019 – 11 a.m. Eastern time

Join Webex meeting   Meeting number: 293 471 896 Meeting password: bJ7mhw36 Join by phone Call-in toll-free number: 1-866-308-0254 (US)  Call-in number: 1-224-357-2801 (US)  Show global numbers  Conference Code: 886 336 9991 

 

• Wednesday, January 30, 2019 – 3 p.m. Eastern time

Join Webex meeting   Meeting number: 292 277 094 Meeting password: 34cMvy2h Join by phone Call-in toll-free number: 1-866-308-0254 (US)  Call-in number: 1-224-357-2801 (US)  Show global numbers  Conference Code: 886 336 9991 

 

• Wednesday, February 6, 2019 – 3 p.m. Eastern time

Join Webex meeting   Meeting number: 291 237 720 Meeting password: D7UPHJ43  Join by phone  Call-in toll-free number: 1-866-308-0254 (US)  Call-in number: 1-224-357-2801 (US) 

Show global numbers  Conference Code: 886 336 9991 

View the recorded training at a time convenient for you:

• A recording of the ProviderPortal training will be available after the live sessions have been completed.
• The recording will be available at www.aimproviders.com/msk/Resources.html.

Take advantage of this opportunity to learn more about how the AIM ProviderPortal can benefit you!

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Please share this notice with other members of your practice and office staff.

 

To search for specific policies or guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.

 

Medical Policies

On September 13, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).

 

Publish date	Medical Policy number	Medical Policy title	New or revised
10/17/2018	MED.00125	Biofeedback and Neurofeedback	New
10/17/2018	SURG.00103	Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)	Revised

 

Clinical UM Guidelines

On September 13, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on September 27, 2018.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or Revised
10/17/2018	CG-DME-46	Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs	New
10/17/2018	CG-SURG-90	Mohs Micrographic Surgery	New
9/20/2018	CG-DRUG-94	Rituximab (Rituxan®) for Non-Oncologic Indications	Revised
10/17/2018	CG-DRUG-107	Pharmacotherapy for Hereditary Angioedema	Revised
9/20/2018	CG-SURG-40	Cataract Removal Surgery for Adults	Revised

While there’s no single, easy answer to the issue of health care disparities, the vision of My Diverse Patients is to harness the power of data and identify ways to bridge gaps often experienced by diverse populations.

 

We’ve heard it all our lives: in order to be fair, you should treat everybody the same. But the challenge is that everybody is not the same — and these differences can lead to critical disparities not only in how patients access health care, but in their outcomes as well.

 

The reality is that the burden of illness, premature death and disability disproportionately affects certain populations.¹ My Diverse Patients features robust educational resources to help support you in addressing these disparities, such as:

• Continuing medical education about disparities, potential contributing factors and opportunities for you to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

 

Accelerate your journey to becoming your patients’ trusted health care partner by visiting https://mydiversepatients.com today.

 

^[1] Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Report. Vol 62 (Suppl 3); p3.

Effective March 1, 2019, Empire BlueCross BlueShield HealthPlus (Empire) will transition its Outpatient Rehabilitation Utilization Management (UM) program to AIM Specialty Health® (AIM), a specialty health benefits company. The Outpatient Rehabilitation UM program includes physical, occupational and speech therapy services.

 

Empire has an existing relationship with AIM in the administration of other programs and is excited to expand this relationship to include outpatient rehabilitation services. AIM works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe and affordable.

 

This transition enables Empire to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will continue to use criteria documented in Empire Clinical UM Guidelines GC.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://www.availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.

 

Detailed prior authorization requirements are available online by accessing the Precertification Lookup Tool at https://www.availity.com under Payer Spaces. Contracted and noncontracted providers can call Provider Services at 1-800-450-8753 for prior authorization requirements or additional questions.

 

You can also authorize these services online through the Interactive Care Reviewer on the Availity Portal. Log on to Availity, select Authorizations and Referrals under the Patient Registration menu and choose Authorizations.

 

Pre-service review requirements

Providers should contact Empire to obtain prior authorization for all outpatient rehabilitation services that are scheduled to be rendered through February 28, 2019. Any authorizations Empire makes prior to the transition date of March 1, 2019, will be honored, and claims will process accordingly.

 

Providers should contact AIM to obtain prior authorization for all services scheduled on or after March 1, 2019. Beginning February 11, 2019, providers will be able to contact AIM for prior authorization on services scheduled to take place on or after March 1, 2019. Providers are strongly encouraged to verify prior authorization has been obtained before scheduling and performing services.

 

How to place a review request

Providers can submit prior authorization requests to AIM in one of the following ways:

• Access AIM ProviderPortalSM directly at https://www.providerportal.com. You will first need to register for this portal at http://aimspecialtyhealth.com/goweb.html. Online access is available 24/7 to process orders in real time and is the fastest and most convenient way to request authorization. Registration opens February 11, 2019.
• Access AIM via the Availity Portal at https://www.availity.com. For any questions, call the AIM Contact Center toll-free number at 1-800-554-0580 Monday through Friday from 8 a.m. to 8 p.m. Eastern time.

 

For more information

For resources to help get started with the Outpatient Rehabilitation UM program, go to www.aimprovider.com/rehabilitation. The AIM provider website provides access to useful information and tools, such as order entry checklists, Clinical UM Guidelines and an FAQ.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

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.

Please continue to check Important Medicare Advantage Updates at empireblue.com/medicareprovider for the latest Medicare Advantage information, including:

• Prior authorization requirements for Colonoscopy and Upper Gastrointestinal Endoscopy  
• 2019 Provider Annual Notice of Change 
• Medicare Advantage Reimbursement Policy October Provider Bulletin  
• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila  
• July Medicare Advantage reimbursement policy  
• Submit PA medication requests electronically; new phone number for MA prescription PAs 
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  
• Inpatient Readmissions   

 

75195MUPENMUB 11/16/2018

 

Empire recently introduced a redesigned monthly Explanation of Benefits (EOB) to Medicare Advantage members.

 

The new EOB includes:

• Personalized tips to help members save on health care expenses.

A preventive care checklist — to point out opportunities for screenings or other care.

Alerts when a claim needs immediate attention.

 

If you or your members have any questions about how to read the new EOB, please call the number on the back of the member ID card.

Empire will offer general and condition-specific Medicare risk adjustment, documentation and coding training in 2019. Additional information will be available at Important Medicare Advantage Updates at empireblue.com/medicareprovider.