January 2020 Empire Provider News

Contents

Federal Employee Program (FEP)CommercialDecember 31, 2019

2020 FEP Benefit information available online

State & FederalMedicaidDecember 31, 2019

Improving the patient experience

State & FederalMedicare AdvantageDecember 31, 2019

Keep up with Medicare News

State & FederalMedicare AdvantageDecember 31, 2019

Electric Boat offers Medicare Advantage options

State & FederalMedicare AdvantageDecember 31, 2019

Medical drug benefit Clinical Criteria updates

State & FederalMedicare AdvantageDecember 31, 2019

Healthcare Quality Patient Assessment Form and Patient Assessment Form

State & FederalMedicare AdvantageDecember 31, 2019

Reminder to Medicare Advantage providers

State & FederalMedicare AdvantageDecember 31, 2019

Help protect your patients by providing medical ID protection - best practices

State & FederalMedicare AdvantageDecember 31, 2019

Medicare preferred continuous glucose monitors

State & FederalMedicare AdvantageDecember 31, 2019

Verifying and updating your provider information

State & FederalMedicaidDecember 31, 2019

Coding spotlight - provider’s guide to coding respiratory diseases

State & FederalMedicaidDecember 31, 2019

Medical drug benefit Clinical Criteria - September 2019

State & FederalMedicaidDecember 31, 2019

Medical drug benefit Clinical Criteria updates - August 2019

State & FederalMedicaidDecember 31, 2019

Verifying and updating your provider information

AdministrativeCommercialDecember 31, 2019

Remittance Inquiry Tool Reminder

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

Here is a reminder on how we’ve made it easy for you to access remittance advices online for all Empire BlueCross BlueShield (“Empire”) members using the Remittance Inquiry tool on the Availity Portal.

 

How to access the remittance inquiry tool:

  • Log in to the Availity Portal.
  • From the Availity home page, select Payer Spaces.
  • Select Empire from the list of payer tiles.
  • Select Applicationsand then Remittance Inquiry.

 

How it works

After selecting the organization, select the tax ID number from the drop-down menu. You can choose multiple search options: electronic funds transfer (EFT) number, check number, payment number or issue date range. If you choose issue date range, you’ll need to select the provider under the Express Entry drop-down or enter the NPI (typically the group NPI). You have the option to sort your results by provider name, issue date, check/EFT/payment  number and check/EFT amount.

Note: To access a capitation payment, you must use the tax id and check/EFT/payment number options.

 

Do you need an imaged copy of the remittance for your files?

Select the View Remittance link associated with each remit and print or save.

  • Remit images are available for all Empire members.
  • Remits of over 50 pages will return the first 50 pages for viewing.
  • To view all pages, download or print the remit.
  • Search in span of seven days and up to 15 months back.
  • To conduct a remittance inquiry, be sure you have the role of “View Claims Status Inquiry”. Contact your administrator if you need this access.

 

Don’t see this valuable tool when you log in to the Availity Portal?

Contact your administrator to request claims status access, which includes the Remittance Inquiry tool. If you do not know who the administrator for your organization is, log in to Availity, go to your account and select My Administrators.

 

If you have questions about the features on the Availity Portal or need additional registration assistance, contact Availity Client Services at 1-800-282-4548.

 

If you have questions about the tools and resources available within Payer Spaces or on the Empire website, contact Provider Services at the number listed on the back of the member’s ID card or your local Provider Relations representative.

 

AdministrativeCommercialDecember 31, 2019

Let Us Help You Accomplish Your 2020 “To Do List” Early - EDI Migration

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

The New Year always gives us an opportunity to set new goals. Starting in 2020, we want to help you check off a few “to do” items. As the Availity migration continues full speed ahead, let’s get you started on your first goals of the year:

 

Don’t Delay and Transition to Availity today!

All EDI transmissions currently sent or received today via the Empire EDI Gateway are now available on the Availity EDI Gateway. 

  • 837- Institutional and Professional
  • 837- Dental
  • 835- Electronic Remittance Advice
  • 276/277- Claim Status
  • 270/271- Eligibility Request
  • 275 – Medical Attachments

 

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

  • Migrate your direct connection with Empire and become a direct submitter with Availity.
  • Use your existing Clearinghouse or Billing Company for your EDI transmissions.  (Work with them to ensure connectivity to the Availity EDI Gateway).
  • Use Direct Single Claim entry through the Availity Portal.
  • Availity setup is simple and at no cost for you!
  • Use this “Welcome” link below to get started today: https://apps.availity.com/web/welcome/#/anthem

 

Learn Something New!

Enroll in one of Availity’s free courses and training demos. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

 

Follow these steps to register at www.Availity.com :

  1. Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).
  2. Select Sessions from the menu under the search catalog field.
  3. Scroll Your Calendar to locate your webinar.
  4. Select View Course and then Enroll. The ALC will email you instructions to attend.

 

If you and your clearinghouse have already migrated, you are a step ahead! If not, take action today to make the transition.

 

For questions contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 8 a.m. - 7 p.m. ET.

 

AdministrativeCommercialDecember 31, 2019

Upcoming retirement planned for legacy Medical Attachment submission tool

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

The Medical Attachment tool makes the process of submitting electronic documentation in support of a claim, simple and streamlined. We are now in the final stages of migration from the Medical Attachments link to the Attachments-New option.

 

What is happening to the current attachment tool?

  • The legacy tool will be retired soon* with access via Attachments-New option available now.
  • The history of the information you have previously submitted is still available on the legacy tool for now*.
  • Read only access to the history  is in the final stages*

 

*Look for messaging on the legacy attachment tool for specific dates

 

How to Access solicited Medical Attachments for Your Office

Availity Administrator, complete these steps:
From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, 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
  3. Assign user access by checking the box in front of the user’s name

 

Using Medical Attachments

Availity User, complete these steps:

  1. Log in to www.availity.com
  2. Select Claims and Payments > Attachments-New >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: Log in and select Help & Training > Get Trained to open the Availity Learning Center (ALC) Catalog in a new browser tab. Search the Catalog by keyword (attachments) to find training demo and on-demand courses. Select Enroll to enroll for a course and then go to your Dashboard to access it any time.

 

AdministrativeCommercialDecember 31, 2019

Availity providers can now receive and respond to medical record requests for post pay audit February 10, 2020

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

We are launching the use of Availity’s medical attachment functionality to begin requesting medical records and itemized bill information from providers electronically instead of paper requests.  This change applies only to the process of requesting and receiving medical records; it is not a change to the audit program.  We began transitioning providers to this new process in an active limited launch in October 2019. We will complete the transition by February 10, 2020.

 

Important facts regarding this change:

  • This change only affects providers who use Availity and who have opted into using the medical attachment functionality through the permissions in Availity’s enrollment center.
  • The new functionality is for medical record requests for post pay claims for the Payment Integrity Quality Claims Review (provider audit) department only.
  • There will be no duplicate requests (both paper and electronic).
  • In Availity, the request will come into the provider’s Medical Attachment “inbox”
    • o The original letter historically sent via paper is accessible through a hyperlink in the Availity system as a pdf electronic copy. The letter content is the same as it was in paper format.
    • o Each electronic request letter will have a timeframe for responding to the request. After the timeframe has passed for that letter, you will not be able to respond to that electronic letter.  If you wish to upload medical records after the response time has expired, please refer to the Availity training referenced below.
    • o Providers can respond to the request by uploading records in Availity. The attachments are received in almost real time and are delivered electronically to the payer’s systems through secure means - - nothing is stored in Availity.
  • The following are not included or not impacted:
    • o Vendor requests for medical records on behalf of the payer.
    • o Providers that do not use Availity or have not turned on permissions for Medical Attachments within Availity.
    • o The request timing or verbiage in the request letter.
    • o At this time, the Program Integrity Special Investigations Unit (SIU) post pay review, but they will be included at a future date.

Resources

Training is available in Availity located here Availity Training on Electronic Medical Records for Program Integrity.

 

Can I start using the functionality earlier?

Yes.  If you chose to opt in earlier, please ensure you are configured within Availity.  You may request early access via this email address: dl-Prod-Availity-Provider-Support@anthem.com.

 

For additional information see our Frequently Asked Questions.

AdministrativeCommercialDecember 31, 2019

Appointment access standards for PCPs, specialty care and behavioral health practitioners

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

As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. Please visit empireblue.com to access our Provider Manual for our guidelines on access to care for primary care practitioners (PCPs), specialty care practitioners (SCPs) and behavioral health practitioners (BHPs). We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

 

  • Assessing the availability of appointments via phone calls by our staff or designated vendor to the provider’s office
  • Analysis of member complaint data
  • Analysis of member satisfaction surveys

 

The following information is excerpted from the Provider Manual for your review:

 

Physician/provider access goals and calendar requirements

One of our goals is to make accessing medical care easy for members by assuring a comprehensive network of physicians and providers close to their homes. As a result, we have implemented the following plan-wide geographic access goals as guidelines for our network. It is our goal to provide members with access to the following within our defined service areas:

  • Two PCPs within five miles of each member
  • Two OB/GYNs within eight miles of each member
  • Full range of specialists (including non-MD allied providers) within 15 miles of each member

 

Calendar access requirements

 

Primary care providers:

 

Preventive care - members scheduling periodic routine exams (well care/preventive visits), appointments should be available within 45 calendar days of a member’s call. Care provided to prevent illness or injury; examples include,

but are not limited to, routine physical examinations, immunizations, mammograms and pap smears.

 

Urgent care appointment with acute symptoms - appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.

 

Routine care with symptoms – must have access to care within five (5) days of the member’s call.

 

Routine check-up – must have access to care within ten (10) business days of the member’s call. This consists of care provided for non-symptomatic visits or follow-up.

 

Though it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs. As a reminder, we now contract with walk-in centers and urgent care facilities which are listed in our directory.

 

Specialists:

 

Urgent care appointment with acute symptoms - appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.

 

Routine check-up – must have access to care within 15 calendar days of the member’s call. Care provided for non-symptomatic visits for health check.

 

Behavioral health providers:

 

Non-life threatening emergency needs - must be seen, or have appropriate coverage directing the member, within six (6) hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms and needs immediate attention; no risk of loss of life.

 

Urgent needs - must be seen, or have appropriate coverage directing the member, within 48 hours. Non-emergent behavioral health illness that requires immediate care; member is experiencing significant psychological distress with

symptoms that impairs daily functioning; no risk of loss of life.

 

Initial routine office visit - must be seen within ten (10) business days. New patient non-urgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.

 

Follow-up routine visit – must be seen within thirty (30) calendar days. Non-urgent behavioral health care; member has been scheduled for a non-urgent consultation or requires services including, but not limited to, follow-up and existing medication management.

 

After-hours coverage

After-hours coverage, which is required by the Participating Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent services outside of regular office hours. Note that telephone answering machines and voice mail are not acceptable means of providing access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911.

 

The recording or live person must refer the patient to urgent care center, 911, or emergency room, and also provide the option to contact a live health care practitioner (via cell, pager, beeper, transfer system) , get a call back for urgent instructions, or be transferred directly to the available practitioner or on-call practitioner.

 

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys, as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document and we understand the reasons that the requirements are not met.

AdministrativeCommercialDecember 31, 2019

The New Year brings New ID Cards for Many Empire Members

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

Now is the time to ask all of your patients to present their current ID card.  Many members were assigned new identification numbers effective January 1, 2020 and new ID cards were provided digitally or mailed to all affected members in late December 2019. To ensure claims are processed appropriately, here is some helpful information.

 

Tips for Success: When Empire BlueCross BlueShield (“Empire”) members arrive at your office or facility, ask to see their current member identification card at each visit. Many of our members no longer receive a paper card so they will present you with their digital card on their mobile device.  Doing so will help you:

  • Identify the member’s product
  • Obtain health plan contact information
  • Speed claims processing

 

Note:  Claims submitted with an incorrect ID number may be unable to be processed and may be returned for correction and resubmission with the correct ID.  

 

Tips for Success: When you contact a member about a claim returned for an invalid ID, and they do not recall receiving a new ID card or they misplaced their ID card, please ask the member to confirm their member ID using one of the following options:

  • Log in to their member account on empireblue.com
  • Use the Empire mobile app called Sydney (formerly Empire Anywhere) to access their electronic ID card
  • Members can fax or email their most current card from empireblue.com or the mobile APP to your office if needed
  • Call their Empire member services number

 

Following the tips above will result in a successful start to your New Year.

AdministrativeCommercialDecember 31, 2019

NYSHIP (New York State Health Insurance Program) change in Hyperbaric Oxygen Therapy claim submissions

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

Effective for dates of service on or after January 1, 2020, Empire BlueCross BlueShield (“Empire”) will consider outpatient claims for NYSHIP members receiving hyperbaric oxygen therapy, whether done as a sole service or in conjunction with another outpatient service.

 

For dates of service prior to January 1, 2020, Empire considered hyperbaric oxygen therapy claims only if billed in conjunction with a qualifying service such as emergency care or surgery service and United Health Care (UHC), NYSHIP’s medical benefit administrator, considered the claims when it was the sole service or billed without a qualifying service.  

 

This only applies to hyperbaric oxygen claims in the outpatient hospital setting.  All claims will still be subject to standard medical necessity guidelines.

AdministrativeCommercialDecember 31, 2019

Postponed: Review of professional claims with emergency room level 5 E/M codes

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

In the May 2019 edition of Provider News, Empire BlueCross BlueShield (“Empire”) communicated to you that we were initiating post-payment reviews for professional ER claims billed with level 5 ER E/M codes 99285 and G0384. Empire’s implementation of this policy has been postponed. This update relates only to the policy announced on May 1, 2019. All other current policies applicable to you, including, but not limited to, other audit or reimbursement policies pertaining to ER claims are unaffected by this update. We will keep you informed about the initiation of the review process; however, as always, we require proper coding and billing to ensure prompt and accurate payment.

Policy UpdatesCommercialDecember 31, 2019

Important Update: Milliman Care Guideline (MCG), 23rd Edition, ORG: W0163 Pelvic Organ Prolapse Repair

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

Effective for dates of service on and after May 1, 2020, the updated clinical UM guideline MCG ORG: W0163 Pelvic Organ Prolapse Repair, will now include the medical necessity review for pelvic organ prolapse repair surgery.

Initially, the clinical guideline only applied for pelvic organ prolapse length of stay review. With this update it will also address the preoperative and post-service medical necessity review of pelvic organ prolapse repair procedures. This change is effective for dates of service on and after May 1, 2020.

This clinical guideline does not apply to Federal Employee Program® (FEP®), Medicare and Medicaid.

Reimbursement PoliciesCommercialDecember 31, 2019

Reimbursement Policy update - Outpatient Facility Edit Implementation

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

Beginning with claims processed on and after April, 26, 2020, we will be enhancing our outpatient facility edits for revenue codes, Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) and modifiers. Enhanced edits include appropriate use of various code combinations which can include,, but are not limited to, procedure code to revenue code, HCPCS to revenue code, type of bill to procedure code, type of bill to HCPCS code,  procedure code to modifier, and HCPCS to modifier.  These edits are based on national correct coding guidelines and principles. The following coding resources are excellent resources to use for guidance; (CPT) codebook, (HCPCS) codebook, National Uniform Billing Committee (NUBC) and the Uniform Billing (UB) Editor codebook.  Additionally, Anthem will begin adoption of the National Correct Coding Initiatives (NCCI) for Outpatient Facilities to include industry-standard column one and column two procedure-to-procedure (PTP) codes.

 

Products & ProgramsCommercialDecember 31, 2019

New Musculoskeletal and Pain Management Solution Effective for Select National ASO Accounts January 1, 2020

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

Musculoskeletal (MSK) care and interventional pain management pose substantial challenges for employers as costs rise, the population ages and physician practice patterns vary widely. With disorders affecting one in every two American adults1, the need for evidence-based care and proactive consumer engagement is essential to better managing care and cost.

 

With that in mind, we are pleased to announce that select National Accounts will utilize the comprehensive Musculoskeletal and Pain Management Solution, administered by AIM Specialty Health. The new MSK program reviews certain spine and joint surgeries/procedures, and interventional pain services against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine.

 

Transition Period

To ensure continuity of care, we will have a 90 day transition of care for members in active treatment for pain management or for members that have received prior approval through Empire. Providers do not need to obtain authorization through AIM for services already in progress or where prior authorization has already been obtained with Empire. 

 

Please contact anthem.com or call the number on the back of the member ID card for member eligibility.

 

1 American Academy of Orthopedic Surgeons

Federal Employee Program (FEP)CommercialDecember 31, 2019

2020 FEP Benefit information available online

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

To view the 2020 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to www.fepblue.org>select Benefit Plans>Brochure & Forms.  Here you will find the Service Benefit Plan Brochure and Benefit Plan Summary information for year 2020.  For questions please contact FEP Customer Service at 1-800-522-5566.

State & FederalMedicaidDecember 31, 2019

Improving the patient experience

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

Category: Medicaid

Are you looking for innovative ways to improve your patients’ health care experiences?

 

Numerous studies have shown a patient’s primary health care experience and, to some extent, their health care outcomes, are largely dependent upon health care provider and patient interactions. That’s why Empire BlueCross BlueShield HealthPlus has an online learning site called My Diverse Patients that offers insight on how to communicate with your diverse patient population, including a course titled: What Matters Most: Improving the Patient Experience. Learn more by visiting the course link or on the My Diverse Patients site at www.mydiversepatients.com.

 

NYE-NU-0175-19 November 2019

State & FederalMedicare AdvantageDecember 31, 2019

Keep up with Medicare News

State & FederalMedicare AdvantageDecember 31, 2019

Electric Boat offers Medicare Advantage options

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

Category: Medicare

Effective January 1, 2020, Electric Boat retirees who are eligible for Medicare Parts A and B will be enrolled in a Medicare PPO plan under Empire BlueCross BlueShield (Empire). The plan includes the National Access Plus benefit, which allows retirees the freedom to receive services from any provider as long as the provider is eligible to receive payments from Medicare. Additionally, Electric Boat retirees will have the same cost share for both in-network and out-of-network covered services. The Medicare Advantage plan offers the same hospital and medical benefits that original Medicare covers, as well as additional benefits that original Medicare does not cover, such as an annual routine physical exam, LiveHealth Online and SilverSneakers.

 

The prefix on Electric Boat ID cards will be ZDX. The cards will also show the National Access Plus icon.

 

Providers can submit claims electronically using the electronic payer ID for the Empire plan in their state or submit a UB-04 or CMS-1500 form to the Empire plan in their state. Claims should not be filed with original Medicare.

 

Detailed prior authorization requirements also are available to contracted providers by accessing the provider self-service tool at https://www.availity.com.

 

EBSCRNU-0081-19 November 2019

#506241MUPENMUB

State & FederalMedicare AdvantageDecember 31, 2019

Medical drug benefit Clinical Criteria updates

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

Category: Medicare

On September 19, 2019, 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 website, and the effective dates will be reflected in the Medicare Advantage Clinical Criteria Web Posting September 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

EBSCRNU-0080-19 November 2019

505908MUPENMUB

State & FederalMedicare AdvantageDecember 31, 2019

Healthcare Quality Patient Assessment Form and Patient Assessment Form

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

Category: Medicare

Empire BlueCross BlueShield (Empire) offers the Healthcare Quality Patient Assessment Form (HQPAF)/Patient Assessment Form (PAF). This newsletter focuses on key tips that may help participating providers successfully close out their 2019 HQPAF/PAF.

 

Dates and tips to remember:

  1. Empire encourages you to review your patient population as soon as possible. You can help patients schedule an in-office visit. These appointments help the patient manage chronic conditions, which impact the health status of the patient.
  2. At the conclusion of each office visit with the patient, providers who are participating in the HQPAF/PAF program are asked to complete and return a HQPAF/PAF. The form should be completed based on information collected during the visit. Participating providers may continue to use the 2019 version of the HQPAF/PAF for encounters taking place on or before December 31, 2019. Empire will accept the 2019 version of the HQPAF/PAF for 2019 encounters until midnight on January 31, 2020. Important note: HQPAF/PAF for 2019 dates of service that are rejected due to provider error and corrected by the provider may be submitted through March 31, 2020.
  3. If not already submitted, participating providers are required to submit an Account Setup Form (ASF), W9 and a completed direct deposit enrollment by March 31, 2020. Participating providers should call 1-877-751-9207 if they have questions regarding this requirement. Failure by a participating provider to comply with this requirement will result in forfeiture of the provider payment for submitted 2019 HQPAF/PAF program, if applicable.

 

If you have any questions about the PAF or HQPAF programs, please call 1‑877‑751‑9207 from 9:30 a.m. to 7:30 p.m. Eastern, time Monday to Friday.

 

EBSCRNU-0078-19 November 2019

506172MUPENMUB

State & FederalMedicare AdvantageDecember 31, 2019

Reminder to Medicare Advantage providers

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

Category: Medicare

As a reminder, PCPs may only refer Empire BlueCross BlueShield (Empire) members to in-network Medicare Advantage providers.

 

Empire has contracted with specialists to ensure adequate care of our members. The use of contracted network specialists will ensure continuity of appropriate clinical background data and coordination of care with the PCP.

 

Should there be a need to refer the member outside the contracted network, contact Empire directly for prior authorization (PA). Referring a Medicare Advantage member out-of-network, who does not have out-of-network benefits, could result in claim denials with member liability unless the service is urgent, emergent, out-of-area dialysis or if PA was approved by the plan.

 

Although not required, PA is encouraged for preferred provider organization (PPO) members who want to receive notification of advanced coverage when utilizing an out-of-network provider for services.

 

As a reminder to all providers, the referring physician name and NPI must be reported on the claim when the PCP does not provide the service rendered. This will reduce the number of rejections issued during initial claim processing.

 

BSCRNU-0074-19 October 2019

504908MUPENMUB

State & FederalMedicare AdvantageDecember 31, 2019

Help protect your patients by providing medical ID protection - best practices

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

Category: Medicare

Overview

Many of our members have reported that they received unsolicited calls (or emails) from an individual or company offering to provide durable equipment devices, such as back or leg braces, or items such as topical creams at little or no cost. While it may be tempting to want to receive something for free, members should know that there is a cost. 

 

Although our members may not receive a bill for these devices or medications, the items are billed to the insurance companies, costing hundreds or even thousands of dollars each.

 

How does this impact members?

Members should also know that the cost may be more than monetary. Allergic reactions may occur when using medications that are not properly prescribed. Ill-fitting leg or back braces, or equipment that is not specifically intended for the pain experienced by the member, could do more harm than good.

 

This problem is prevalent throughout the country, so all of our members should be aware. Billions of unsolicited telemarketing calls are made each year, many of which are promoting health care services. Calls often spoof local phone numbers or numbers that appear familiar to trick the recipient into accepting the call. 

 

How can I help protect my patients?

While the ultimate purpose of these telemarketing calls is to sell these items, the immediate goal of the person or company placing the call is to obtain valuable personally identifiable information (PII) from the member. Without this personal information, such as a social security number or insurance identification number, selling these devices and medications is much more difficult. Share this information with you patients to help them learn how to protect their PII.

 

You can help protect your patients and their personally identifiable information from scams by reminding them of the following:

  • Don’t fall prey to scams!
  • Take a few moments to review your Explanation of Benefits (EOB) and the services listed.  
  • When receiving robotic (robo) or telemarketing calls:
    • Simply hang up the phone.
    • Beware of threatening or urgent language used by the caller.
    • Do not provide any personally identifiable information such as your social security number or insurance identification number. The caller may imply that they have your information and ask you to provide it to confirm that they have the correct information. Do not provide the information or confirm it if they do happen to have any identification information.
  • When receiving emails:
    • Do not open email attachments you weren’t expecting.
    • Check for spelling mistakes and poor grammar.
    • Do not click on the links you are sent. You can type the link into a new browser.
    • Online scams can come from anywhere. Take a few moments to review your EOB and confirm that you received the services listed on the EOB.
  • Additional ways to protect yourself:
    • Shred or destroy obsolete documents that contain medical claims information or EOBs.
    • Do not use social media to share medical treatment information.

 

How to report when you receive what you suspect is a scam call or email:

  1. To file a complaint with the Federal Trade Commission, you can go to: https://ftc.gov/complaint or call 1-877-FTC-HELP.
  2. Members may contact their plan’s Member Services department.

 

EBSCRNU-0070-19 November 2019

505755MUPENMUB

State & FederalMedicare AdvantageDecember 31, 2019

Medicare preferred continuous glucose monitors

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

Category: Medicare

On January 1, 2020, Empire BlueCross BlueShield (Empire) will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by Empire will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests, call 1-833-293-0661.

 

EBSCRNU-0056-19 August 2019

503236MUPENMUB

State & FederalMedicare AdvantageDecember 31, 2019

Reminder: Medicare claims for secondary payer must be submitted after the 30-day Medicare remittance period

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

Category: Medicare

Claims will deny when a provider submits a Medicare claim to Empire BlueCross BlueShield (Empire) as a secondary payer if the claim has been received prior to the 30-day Medicare remittance period. Providers submitting a paper claim for Medicare claims that are filed with Medicare as the first payer must not file with Empire as the secondary payer until the 30-day remittance period has expired.

 

These claims rejections are a result of improper timely filing by providers. To eliminate claims rejections when Empire is the secondary payer, submit the claim 30 days after the Medicare Remittance period.

 

For additional information, call the number on the back of the member’s ID card.

 

EBSCARE-0223-19 November 2019

505847MUPENMUB

State & FederalMedicare AdvantageDecember 31, 2019

Verifying and updating your provider information

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

Category: Medicare

Maintaining accurate provider information is critically important to ensure that our members have timely and accurate access to care.Additionally, Empire BlueCross HealthPlus is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements. To remain compliant with federal and state requirements, changes must be communicated within 30 days in advance of a change or as soon as possible.

 

Key data elements include physician name, address, phone number, accepting new patient status, hospital affiliations and medical group affiliations.

 

Please notify us by completing the Provider Maintenance Form available at https://www.empireblue.com/provider/provider-maintenance-form. Thank you for your help and continued efforts in keeping our records up to date.

 

NYE-NU-0180-19 November 2019

State & FederalMedicaidDecember 31, 2019

Coding spotlight - provider’s guide to coding respiratory diseases

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

Category: Medicaid

ICD-10-CM coding

Respiratory diseases are classified in categories J00 through J99 in Chapter 10, “Diseases of the Respiratory System” of the ICD-10-CM Official Guidelines for Coding and Reporting.

 

Pneumonia

Pneumonia is coded in several ways in ICD-10-CM. Combination codes that account for both pneumonia and the responsible organism are included in Chapter 1, “Certain Infectious and Parasitic Diseases” and Chapter 10, “Diseases of the Respiratory System.” Examples of appropriate codes for pneumonia include:

  • J15.0 — pneumonia due to Klebsiella
  • J15.211 — pneumonia due to Staphylococcus aureus
  • J11.08 + J12.9 — viral pneumonia with influenza.

 

Other types of pneumonia are coded as manifestations of underlying infections classified in chapter 1; two codes are required in such cases. Examples of this dual classification coding include I00 + J17 — pneumonia in rheumatic fever. When the diagnostic statement is pneumonia without any further specification and the organism is not identified, the assigned code is J18.9 — pneumonia, unspecified organism.

 

Influenza

ICD-10-CM classifies influenza as the following categories:

  • J09 — due to certain identified influenza viruses
  • J10 — due to other identified influenza virus
  • J11 — due to unidentified influenza virus.

 

Codes from categories J09 and J10 should be assigned only for confirmed cases of avian flu and other novel influenza A, or for other identified influenza virus.

 

Chronic obstructive pulmonary disease (COPD) and asthma

COPD is a general term used to describe a variety of conditions that result in obstruction of the airway. ICD-10-CM classifies these conditions to category J44, other chronic obstructive pulmonary disease. Category J44 includes the following conditions:

  • Asthma with chronic obstructive pulmonary disease
  • Chronic asthmatic (obstructive) bronchitis
  • Chronic bronchitis with airways obstruction
  • Chronic bronchitis with emphysema
  • Chronic emphysematous bronchitis
  • Chronic obstructive asthma
  • Chronic obstructive bronchitis
  • Chronic obstructive tracheobronchitis

 

Category J44 is further subdivided to specify whether there is an acute lower respiratory infection (J44.0) and whether there is an exacerbation of the condition (J44.1). If applicable, a code from category J45 is assigned to specify the type of asthma. It is appropriate to code both the COPD with acute exacerbation and COPD with a lower respiratory infection. Be specific in the documentation, including the type of infection and the infective agent.

 

For COPD, document severity as either mild, moderate or severe. COPD can occur with or without acute or chronic respiratory failure, so any respiratory failure should be separately noted.

 

Asthma is classified into category J45; a fourth character indicates the severity as either mild intermittent, mild persistent, moderate persistent, severe persistent, other and unspecified; also, a final character indicates whether the condition is uncomplicated, or whether status asthmaticus or exacerbation is present.

 

Asthma characterized as obstructive or diagnosed in conjunction with COPD is classified to category J44 — other chronic obstructive pulmonary disease. If the specific type of asthma is documented, also use code J45.

 

Signs and symptoms of COPD or asthma that are separately reported when they occur include hypercapnia, hypoxemia, polycythemia, and acute or chronic respiratory failure. Document any dependence on a ventilator or supplemental oxygen.

 

A diagnosis of asthmatic bronchitis without further specification is coded as J45.9 if the diagnosis is stated as exacerbated or acute chronic asthmatic bronchitis, code J44.1 is assigned. A diagnosis of asthmatic bronchitis with COPD or chronic asthmatic bronchitis is coded to J44.9.

Examples of coding for asthma include the following:

  • J45.902 — asthmatic bronchitis with status asthmaticus
  • J44.9 + J45.40 — moderate persistent asthma with COPD.

 

In addition to codes in categories J44 and J45, codes may also be assigned to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco dependence (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17. or tobacco use (Z72.0)

 

HEDIS® quality measures for respiratory conditions

 

Medication Management for People with Asthma (MMA)

This HEDIS measure looks at patients who have been identified as having persistent asthma and have been dispensed appropriate medication on which they remained during the treatment period.

 

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

 

Two rates are reported:

  • The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period
  • The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period

 

For patients with asthma, you should:

  • Prescribe controller medication.
  • Educate them on identifying asthma triggers and taking controller medications.
  • Create an asthma action plan (document in the medical record).
  • Remind them to get their controller medication filled regularly.
  • Remind them to continue taking the controller medications even if they are feeling better and free of symptoms.

 

Exclusions:

  • Acute respiratory failure
  • Chronic respiratory conditions due to fumes/vapors
  • COPD
  • Cystic fibrosis
  • Emphysema
  • Other emphysema

 

Asthma Medication Ratio (AMR)

This HEDIS measure looks at patients who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year.

 

Helpful tips:

  • For each member, count the units of asthma controller medications dispensed during the measurement year.
  • For each member, count the units of asthma reliever medications dispensed during the measurement year.
  • For each member, sum the units calculated in step 1 and step 2 to determine units of total asthma medications.
  • For each member, calculate the ratio of controller medications to total asthma medications (units of controller medications divided by units of total asthma).

 

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

This HEDIS measure looks at members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.

 

Helpful tips:

  • Managing chronic conditions takes planning. A pre-visit chart review is a good place to start.
  • Proper diagnosis is needed to ensure members receive appropriate short- and long-term treatment.
  • Both symptomatic and asymptomatic patients suspected of COPD should have spirometry performed to establish airway limitation and severity.

Resources:

  • ICD-10-CM Expert for Physicians: the complete official code set. Optum360, LLC. 2019.
  • ICD-10-CM/PCS Coding: theory and practice. 2019/2020 Edition. Elsevier
  • NCQA: HEDIS & performance management: https://www.ncqa.org/hedis/measures

 

NYE-NU-0179-19 November 2019

State & FederalMedicaidDecember 31, 2019

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.

Category: Medicaid

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/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 view a guideline, visit https://www11.empireblue.com/ny_search.html.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

  • *GENE.00023 — Gene Expression Profiling of Melanomas
    • o Expanded Scope to include testing for the diagnosis of melanoma
    • o Updated INV&NMN statement to include suspicion of melanoma
  • *GENE.00046 — Prothrombin G20210A (Factor II) Mutation Testing
    • o Revised title
    • o Expanded scope and position statement to include all prothrombin (factor II) variations
  • *MED.00110 — Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
    • o Revised title
    • o Added new INV&NMN statements addressing Autologous adipose-derived regenerative cell therapy and use of autologous protein solution
  • *SURG.00052 — Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
    • o Revised title
    • o Combined the three INV&NMN statements into a single statement
    • o Added Intraosseous basivertebral nerve ablation to the INV&NMN statement
  • *TRANS.00035 — Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases
    • o Revised title
    • o Expanded Position Statement to include non-hematopoietic adult stem cell therapy
  • *CG-ANC-07 — Inpatient Interfacility Transfers
    • Added NMN statements regarding admission and subsequent care at the receiving facility
  • *CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities
    • Revised title
    • Expanded Scope
    • Revised MN statement to include upper extremities
  • The following AIM Specialty Health® updates were approved:
    • o *Spine Surgery
    • o *Radiation Oncology-Brachytherapy Brachytherapy, intensity modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) treatment guidelines
    • o Sleep Disorder Management Diagnostic & Treatment Guidelines
    • o Advanced Imaging
      • Imaging of the Heart: Cardiac CT for Quantitative Evaluation of Coronary Calcification
      • *Imaging of the Abdomen and Pelvis
    • MCG Customization for Repair of Pelvic Organ Prolapse (W0163) — Updated Coding Section

 

Medical Policies

On August 22, 2019, 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

9/25/2019

MED.00130

Surface Electromyography Devices for Seizure Monitoring

New

8/29/2019

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

8/29/2019

DRUG.00082

Daratumumab (DARZALEX®)

Revised

9/25/2019

GENE.00010

Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Revised

9/25/2019

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

9/25/2019

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

8/29/2019

OR-PR.00003

Microprocessor Controlled Lower Limb Prosthesis

Revised

8/29/2019

RAD.00023

Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

Revised

9/25/2019

SURG.00129

Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Revised

7/30/2019

MED.00129

Gene Therapy for Spinal Muscular Atrophy

Revised

Clinical UM Guidelines

On August 22, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines adopted by the medical operations committee for Empire members on September 26, 2019.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

8/29/2019

CG-DME-47

Noninvasive Home Ventilator Therapy for Respiratory Failure

New

9/25/2019

CG-MED-84

Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting

New

9/25/2019

CG-SURG-103

Male Circumcision

New

11/20/2019

CG-GENE-12

PIK3CA Mutation Testing

New

9/25/2019

CG-GENE-02

Analysis of RAS Status Previous title: Analysis of KRAS Status

Revised

11/20/2019

CG-MED-39

Bone Mineral Density Testing Measurement Previous title: Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry

Revised

9/25/2019

CG-MED-68

Therapeutic Apheresis

Revised

9/25/2019

CG-REHAB-08

Private Duty Nursing in the Home Setting

Revised

9/25/2019

CG-SURG-52

Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

Revised

9/25/2019

CG-SURG-63

Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

Revised

11/20/2019

CG-SURG-78

Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies Previous Title: Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

Revised

9/25/2019

CG-SURG-79

Implantable Infusion Pumps

Revised

9/25/2019

CG-SURG-83

Bariatric Surgery and Other Treatments for Clinically Severe Obesity

Revised

 

NYE-NU-0177-19 November 2019

State & FederalMedicaidDecember 31, 2019

Medical drug benefit Clinical Criteria - September 2019

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

Category: Medicaid

On September 19, 2019, 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 website, and the effective dates will be reflected in the Clinical Criteria Web Posting September 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

NYE-NU-0182-19 November 2019

State & FederalMedicaidDecember 31, 2019

Medical drug benefit Clinical Criteria updates - August 2019

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

Category: Medicaid

This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).

 

On August 16, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

NYE-NU-0176-19 October 2019

505536MUPENMUB

State & FederalMedicaidDecember 31, 2019

Verifying and updating your provider information

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

Category: Medicaid

Maintaining accurate provider information is critically important to ensure that our members have timely and accurate access to care.Additionally, Empire BlueCross HealthPlus is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements. To remain compliant with federal and state requirements, changes must be communicated within 30 days in advance of a change or as soon as possible.

 

Key data elements include physician name, address, and phone number, accepting new patient status, hospital affiliations and medical group affiliations.

 

Please notify us by completing the Provider Maintenance Form available at https://www.empireblue.com/provider/provider-maintenance-form. Thank you for your help and continued efforts in keeping our records up to date.

 

NYE-NU-0180-19 November 2019