January 2019 Empire Provider Newsletter

Contents

Policy UpdatesCommercialDecember 31, 2018

Policy updates

Medical Policy & Clinical GuidelinesCommercialDecember 31, 2018

Update on clinical guidelines communicated in October 2018 provider newsletter

Medical Policy & Clinical GuidelinesCommercialDecember 31, 2018

Clinical Guideline Updates

Medical Policy & Clinical GuidelinesCommercialDecember 31, 2018

Medical Policy Updates

PharmacyCommercialDecember 31, 2018

Simplifying medication prior authorization processes

PharmacyCommercialDecember 31, 2018

Pharmacy information available on empireblue.com

PharmacyCommercialDecember 31, 2018

Update regarding drugs not approved by the FDA

State & FederalMedicaidDecember 31, 2018

My Diverse Patients: A website to support your diverse patients

State & FederalMedicare AdvantageDecember 31, 2018

Keep up with Medicare news

State & FederalMedicare AdvantageDecember 31, 2018

Medicare Advantage member Explanation of Benefits redesigned

State & FederalMedicare AdvantageDecember 31, 2018

Empire offers risk adjustment and documentation training

AdministrativeCommercialDecember 31, 2018

Clinical practice and preventive health guidelines available online

Beginning 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.

AdministrativeCommercialDecember 31, 2018

HEDIS 2019 starts early February

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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).

AdministrativeCommercialDecember 31, 2018

Benefits to be available for chronic care management and advance care planning services effective February 23, 2019

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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. 

AdministrativeCommercialDecember 31, 2018

Reminder: HCPCS code A0998 Ambulance response and treatment with no transport is active and available for use

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

AdministrativeCommercialDecember 31, 2018

Streamline Workflow with Medical Attachments Tool

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

AdministrativeCommercialDecember 31, 2018

Final Notice: Empire Facility and Physician Portal Retirement - January 9, 2019

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

AdministrativeCommercialDecember 31, 2018

Attention: Updated or New Fee Schedules for Commercial products

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

Policy UpdatesCommercialDecember 31, 2018

Policy updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

Medical Policy & Clinical GuidelinesCommercialDecember 31, 2018

Update on clinical guidelines communicated in October 2018 provider newsletter

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

In the October 2018 issue of our provider newsletter in the ‘Clinical Guideline Updates’, we incorrectly advised that the following guideline would be archived effective January 1, 2019.
  • CG-SURG-66 - Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

 

Please be advised that this guideline will not be archived in January. We apologize for the error.

Medical Policy & Clinical GuidelinesCommercialDecember 31, 2018

Clinical Guideline Updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Revised Clinical Guideline Effective 11-15-2018

(The following adopted guideline was revised to expand medical necessity indications or criteria.)

  • CG-DRUG-88 - Dupilumab (Dupixent®)

 

Revised Clinical Guidelines Effective 12-12-2018

(The following adopted guidelines were revised to expand medical necessity indications or criteria.)

  • CG-DRUG-62 - Fulvestrant (FASLODEX®)
  • CG-DRUG-63 -Levoleucovorin Products
  • CG-DRUG-78 - Antihemophilic Factor and Clotting Factors
  • CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema
  • CG-GENE-03 - BRAF Mutation Analysis
  • CG-SURG-60 - Cervical Total Disc Arthroplasty
  • CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy [Note: Content for Lutetium Lu 177 dotatate (Lutathera®) moved from DRUG.00098 Lutetium Lu 177 dotatate (Lutathera®)]

 

Revised Clinical Guidelines Effective 12-12-2018

(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)

  • CG-DRUG-38 - Pemetrexed Disodium (Alimta®)
  • CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase)
  • CG-DRUG-44 - Pegloticase (Krystexxa®)
  • CG-DRUG-45 - Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)
  • CG-DRUG-54 - Agalsidase beta (Fabrazyme®)
  • CG-DRUG-64 - FDA-Approved Biosimilar Products
  • CG-DRUG-66 - Panitumumab (Vectibix®)
  • CG-DRUG-70 - Eribulin mesylate (Halaven®)
  • CG-DRUG-71 - Ziv-aflibercept (Zaltrap®)
  • CG-DRUG-75 - Romiplostim (Nplate®)
  • CG-DRUG-76 - Plerixafor Injection (Mozobil™)
  • CG-DRUG-79 - Siltuximab (Sylvant®)
  • CG-DRUG-80 - Cabazitaxel (Jevtana®)
  • CG-DRUG-87 - Vedolizumab (Entyvio®)
  • CG-MED-19 - Custodial Care
  • CG-MED-26 - Neonatal Levels of Care
  • CG-MED-67 - Melanoma Vaccines
  • CG-MED-68 - Therapeutic Apheresis
  • CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
  • CG-SURG-60 - Cervical Total Disc Arthroplasty
  • CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver
  • CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors

 

Revised Clinical Guideline Effective 12-12-2018

(The following adopted guideline was updated with new procedure and/or diagnosis codes.)

  • CG-DRUG-16 - White Blood Cell Growth Factors

 

Revised Clinical Guidelines Effective 12-27-2018

(The following adopted guidelines were updated with new procedure and/or diagnosis codes.)

  • CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
  • CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
  • CG-DRUG-29 - Hyaluronan Injections
  • CG-DRUG-61 – Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications
  • CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
  • CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions

 

Archived Clinical Guidelines Effective 01-01-2019

(The following adopted guideline has been archived and has been replaced by AIM guidelines.)

  • CG-SURG-60 - Cervical Total Disc Arthroplasty

 

Revised Clinical Guidelines Effective 01-01-2019

(The following adopted guidelines were revised and had no significant changes to the policy position or criteria.)

  • CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton [Note: Non-invasive electrical bone growth stimulation of the of the spine transitioned to AIM guidelines effective 01-01-2019
  • CG-MED-65 - Manipulation Under Anesthesia [Note: Manipulation under anesthesia of the shoulder transitioned to AIM guidelines effective 01-01-2019]

 

Adopted Clinical Guidelines Effective 01-03-2019

(The following guidelines were previously medical policies and have been adopted and have no significant changes.)

  • CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems [Note: Content moved from MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems.]
  • CG-MED-80 - Positron Emission Tomography (PET) and PET/CT Fusion [Note: Content moved from RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion.]

 

Revised Clinical Guideline Effective 01-12-2019

(The following adopted guideline was updated with new procedure and/or diagnosis codes.)

  • CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Revised Clinical Guidelines Effective 04-01-2019

(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)
  • CG-GENE-01 - Janus Kinase 2 (JAK2)V617F Gene Mutation Assay Title change: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
  • CG-SURG-27 - Sex Reassignment Surgery

 

Revised Clinical Guideline Effective 04-13-2019

(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-SURG-61 - Cryosurgical Ablation of Solid Tumors Outside the Liver

Medical Policy & Clinical GuidelinesCommercialDecember 31, 2018

Medical Policy Updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Revised Medical Policies Effective 11-15-2018

(The following policies were revised to expand medical necessity indications or criteria.)

  • DRUG.00046 - Ipilimumab (Yervoy®)
  • DRUG.00071 - Pembrolizumab (Keytruda®)
  • DRUG.00075 - Nivolumab (Opdivo®)
  • MED.00109 - Corneal Collagen Cross-Linking
  • SURG.00120 - Internal Rib Fixation Systems
  • SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

 

Revised Medical Policies Effective 12-12-2018

(The following policies were revised to expand medical necessity indications or criteria.)

  • DRUG.00062 - Obinutuzumab (Gazyva®)
  • DRUG.00090 - Bezlotoxumab (ZINPLAVA™)
  • DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®)
  • SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
  • SURG.00121 - Transcatheter Heart Valve Procedures
  • TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome

 

Archived Medical Policy Effective 12-12-2018

(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)

  • DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®) [Note: Content transferred to CG-THER-RAD-03 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy]

 

Revised Medical Policies Effective 12-12-2018

(The following policies were reviewed and had no significant changes to the policy position or criteria.)

  • ADMIN.00001 - Medical Policy Formation
  • BEH.00002 - Transcranial Magnetic Stimulation
  • DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
  • DRUG.00034 - Insulin Potentiation Therapy
  • DRUG.00063 - Ofatumumab (Arzerra®)
  • DRUG.00074 - Alemtuzumab (Lemtrada®)
  • DRUG.00077 - Monoclonal Antibodies to Interleukin-17A
  • DRUG.00086 - Mecasermin (Increlex®)
  • DRUG.00099 - Cerliponase Alfa (Brineura™)
  • DRUG.00110 - Inotuzumab ozogamicin (Besponsa®)
  • DRUG.00111 - Monoclonal Antibodies to Interleukin-23
  • DRUG.00116 - Vestronidase alfa (Mepsevii™)
  • DRUG.00118 - Copanlisib (Aliqopa®)
  • GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing
  • GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
  • GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
  • GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
  • GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility
  • GENE.00035 - Genetic Testing for TP53 Mutations
  • GENE.00044 - Analysis of PIK3CA Status in Tumor Cells
  • LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
  • LAB.00029 - Rupture of Membranes Testing in Pregnancy
  • MED.00041 - Microvolt T-Wave Alternans
  • MED.00055 - Wearable Cardioverter Defibrillators
  • MED.00085 - Antineoplaston Therapy
  • MED.00121 - Implantable Interstitial Glucose Sensors
  • RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
  • RAD.00036 - MRI of the Breast
  • RAD.00061 - PET/MRI
  • RAD.00065 - Radiostereometric Analysis (RSA)
  • SURG.00019 - Transmyocardial Revascularization
  • SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
  • SURG.00052 - Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
  • SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
  • SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
  • SURG.00130 - Annulus Closure After Discectomy
  • SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
  • TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
  • TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
  • TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
  • TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
  • TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised Medical Policies Effective 12-27-2018

(The following policies were updated with new procedure and/or diagnosis codes.)

  • DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
  • DRUG.00080 - Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
  • DRUG.00108 - Edaravone (Radicava®)
  • DRUG.00109 - Durvalumab (Imfinzi®)
  • GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
  • GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
  • GENE.00023 - Gene Expression Profiling of Melanomas
  • GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
  • LAB.00011 - Analysis of Proteomic Patterns
  • LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
  • MED.00109 - Corneal Collagen Cross-Linking
  • MED.00111 - Intracardiac Ischemia Monitoring
  • MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
  • OR-PR.00005 - Upper Extremity Myoelectric Orthoses
  • SURG.00007 - Vagus Nerve Stimulation
  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia and Other Genitourinary Conditions
  • SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
  • SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
  • SURG.00111 - Axial Lumbar Interbody Fusion
  • SURG.00113 - Artificial Retinal Devices
  • SURG.00150 - Leadless Pacemaker
  • THER-RAD.00009 - Intraocular Epiretinal Brachytherapy

 

Revised Medical Policies Effective 01-01-2019

(The following policies were updated with new procedure and/or diagnosis codes.)

  • DRUG.00096 - Ibalizumab-uiyk (Trogarzo™)
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases

 

Archived Medical Policy Effective 01-01-2019

(The following policy has been archived and has been replaced by AIM guidelines.)

  • SURG.00066 - Percutaneous Neurolysis for Chronic Neck and Back Pain

 

Archived Medical Policies Effective 01-03-2019

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • MED.00100 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems [Note: Content transferred to new CG-MED-79]
  • RAD.00002 - Positron Emission Tomography (PET) and PET/CT Fusion [Note: Content transferred to new CG-MED-80]

 

Revised Medical Policies Effective 01-12-2019

(The following policies were updated with new procedure and/or diagnosis codes.)

  • MED.00120 - Voretigene neparvovec-rzyl (Luxturna™)
  • MED.00123 - Axicabtagene ciloleucel (Yescarta®)
  • MED.00124 - Tisagenlecleucel (Kymriah®)

 

Revised Medical Policy Effective 04-01-2019

(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • DRUG.00071 - Pembrolizumab (Keytruda®)

 

Revised Medical Policy Effective 04-13-2019

(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

New Medical Policy Effective 04-13-2019

(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders

PharmacyCommercialDecember 31, 2018

Simplifying medication prior authorization processes

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Empire is committed to offering efficient and streamlined solutions for submitting prior authorizations (PAs).  This helps reduce the administrative burden while improving the member experience for their patients.

 

Empire’s Proactive PA process approves select drugs in real time, using an automated prior authorization (PA) process. Proactive PA uses integrated medical and pharmacy data to seamlessly approve medication prior authorization requests where diagnoses are required. Empire’s prior authorization process helps to ensure clinically appropriate use of medications.

 

Providers can take advantage of the electronic prior authorization (ePA) submission process by logging in at covermymeds.com. Creating an account is FREE, and many prior authorizations are approved in real time. Read more about the ePA submission process here.

 

Additionally, providers may be able to access real-time, patient-specific prescription drug benefits information through their electronic medical record (EMR) system. To learn more about this feature, read the full article here.

PharmacyCommercialDecember 31, 2018

Pharmacy information available on empireblue.com

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 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 drug list is reviewed and updates are posted to the web site quarterly (the first of the month for January, April, July and October).

 

Pharmacy updates may be accessed at empireblue.com/provider/  select “Pharmacy Information”.

 

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.  

PharmacyCommercialDecember 31, 2018

Update regarding drugs not approved by the FDA

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Empire continually monitors and updates the list of drugs not approved by the Food and Drug Administration (FDA), which are considered non-covered under prescription drug benefits. When drugs are added to this list, Empire notifies impacted members that the drug is not FDA approved and will no longer be covered.

 

Effective December 1, 2018, these drugs were added to our list of drugs not approved by the FDA.

 

For new members just beginning an Empire plan or not yet having used one of these non-FDA-approved drugs, coverage for these drugs ended December 1, 2018.

 

Existing members who had been identified as already using at least one of the drugs added to the list received a letter to let them know their drug(s) will no longer be covered after December 31, 2018. However, if the patient had a prior authorization for a drug on this list, coverage for that drug continued until the prior authorization expired on December 31, 2018.

 

State & FederalMedicaidDecember 31, 2018

New Provider Learning Opportunity: Put the ProviderPortal to Work for You

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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!

State & FederalMedicaidDecember 31, 2018

Medical Policies and Clinical Utilization Management Guidelines update

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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

State & FederalMedicaidDecember 31, 2018

My Diverse Patients: A website to support your diverse patients

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

State & FederalMedicaidDecember 31, 2018

Transition of Outpatient Rehabilitation Utilization Management program

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

State & FederalMedicare AdvantageDecember 31, 2018

Keep up with Medicare news

State & FederalMedicare AdvantageDecember 31, 2018

Medicare Advantage member Explanation of Benefits redesigned

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.

State & FederalMedicare AdvantageDecember 31, 2018

Empire offers risk adjustment and documentation training

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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.