Blue High-Performance Networks^® (BlueHPN) first went live January 1, 2021, in more than 50 cities across the country. Since then, our national customer base has grown. Even more members are enrolled in plans with access to our BlueHPN for the 2022 benefit year. As a reminder, BlueHPN is a national network designed from our local market expertise and strong provider relationships, aligned with local networks across the country. These local networks are connected to the national chassis to form a national BlueHPN network.

 

In New York, Empire BlueCross BlueShield (“Empire”) is offering large and small group employers plans with access to the BlueHPN, with the existing Connection network as the New York HPN entry.

 

Member ID cards and other plan material feature one small change for 2022:  BlueHPN is now a single word rather than two.

 

As was true in 2021, in 2022 you may see patients accessing the BlueHPN/Connection network through EPO plans or HSA plans with an EPO network. Under these plans, out of network benefits are limited to emergency or urgent care. Be sure to continue to verify patient eligibility and benefits.

 

1492-0122-PN-NY

Parents may not understand the importance of taking their children to the doctor when they are healthy. The benefits are documented by the American Academy of Pediatrics¹ as well as the Centers for Disease Control and Prevention² and it all starts with a recommendation by you, the trusted physician. Share these benefits with parents during regularly scheduled well-visits, or even during sick visits, to reinforce the importance of staying on track:

• Prevention. Regular wellness visits ensure children receive scheduled immunizations that prevent illness. It is also a great opportunity to discuss nutrition and safety in the home.
• Growth and development. Evaluating children for growth and development enables parents to see how much their children have grown since the last visit. It is also an opportunity to share the children’s development, to discuss milestones, social behaviors, and learning.
• Raising concerns. Offering parents an opportunity to share concerns at the start of the visit will help in your evaluation of the patient. They may want to talk about development, sleep and eating habits and behaviors.
• Team approach. Regular visits create strong, trustworthy relationships among physician, parent, and child. The American Academy of Pediatrics (AAP) supports well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental, and social health of a child.

 

Measure up: Well-Child Visits in the first 30 months of life (W30)

This HEDIS® measure is described as the percentage of members who had to the following number of well-child visits with a PCP during the last 15 months. These rates are reported:

• Well-child visits in the first 15 months: Six or more well-child visits with children who turned age 15 months during the measurement year.
• Well-child visits for ages 15 to 30 months: Two or more well-child visits with children who turned age 30 months during the measurement year.

 

Tips

• Telehealth visits are acceptable in meeting the measurement requirements.
• Consider scheduling well-child visits in advance of the child reaching the age for the visit.

 

Coding

• ICD-10:110, Z00.111, Z00.121, Z00.129, Z00.2, Z00.3, Z02.5, Z76.1, Z76.2
• HCPCS: G0438-G0439, S0302
• CPT: 99381-99382, 99391-99392, 99461

 

¹Parent Plus: Importance of routine pediatrician visits. American Academy of Pediatrics. https://publications.aap.org/aapnews/news/12481?autologincheck=redirected

²Catch up on well-child visits and recommended vaccinations. Centers for Disease Control and prevention. cdc.gov/vaccines/parents/visit/vaccination-during-COVID-19.html 

 

1509-0122-PN-NY

 

Effective January 1, 2022, CVS Specialty Pharmacy* and IngenioRx Specialty Pharmacy* will no longer distribute the brand name drug Botox,^® but it will still be available to Empire BlueCross BlueShield HealthPlus (Empire) members either through buy and bill or through an available retail pharmacy.

 

Please note:

• This is not a change in member benefits. This is a change in the Botox vendor only.
• If the member is not using CVS Specialty Pharmacy or IngenioRx Specialty Pharmacy to obtain Botox, no action is needed.

 

For Botox managed under a member’s medical benefit

Effective January 1, 2022, you will need to buy this drug and bill Empire.

 

If you have questions regarding a member’s medical specialty pharmacy benefits, call Provider Services at 1-800-450-8753.

 

For Botox managed under a member’s pharmacy benefit

Effective January 1, 2022, members who currently obtain Botox through IngenioRx Specialty Pharmacy using their pharmacy benefit must change to another in-network pharmacy that distributes Botox.

 

If you have questions regarding a member’s pharmacy benefit, call Pharmacy Member Services at
1-833-207-3117.

 

* CVS is an independent company providing pharmacy services on behalf of Empire BlueCross BlueShield HealthPlus. IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0381-21 November 2021

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

The HEDIS^® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality health-care services. 

 

The ECDS Reporting Standard provides a method to collect, and report structured electronic clinical data for HEDIS quality measurement and improvement. 

 

Benefits to providers:

• Reduced burden of medical record review for quality reporting
• Improved health outcomes and care quality due to greater insights for more specific patient-centered care

 

ECDS reporting is part of the National Committee for Quality Assurance’s (NCQA) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures. 

 

Learn more about NCQA’s digital quality system and what it means to you and your practice, at the following link: https://www.ncqa.org/hedis/the-future-of-hedis/hedis-electronic-clinical-data-system-ecds-reporting/.

 

ECDS measures

The first publicly reported measure using the HEDIS ECDS Reporting Standard is the Prenatal Immunization Status (PRS) measure.  In 2022, NCQA will include the PRS measure in Health Plan Ratings for Medicaid and Commercial plans for measurement year 2021.

 

For HEDIS measurement year 2022, the following measures can be reported using ECDS: 

• Childhood Immunization Status (CIS-E)*
• Immunizations for Adolescents (IMA-E)*
• Breast Cancer Screening (BCS-E)
• Colorectal Cancer Screening (COL-E)
• Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)*
• Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
• Depression Remission or Response for Adolescents and Adults (DRR-E)
• Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
• Adult Immunization Status (AIS-E)
• Prenatal Immunization Status (PRS-E) (Accreditation measure for 2021)
• Prenatal Depression Screening and Follow-Up (PND-E)
• Postpartum Depression Screening and Follow-Up (PDS-E)

 

* Indicates that this is the first year that the measure can be reported using ECDS

Of note, NCQA added the ECDS reporting method to three existing HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening and Follow-up Care for Children Prescribed ADHD Medication. Initially, the ECDS method will be optional which provides health plans an opportunity to try out reporting using the ECDS method before it is required to transition to ECDS only in the future.

 

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

 

NYE-NU-0384-21 November 2021

 

Consumer Assessment of Healthcare Providers and Systems (CAHPS^Ò) is an annual standardized survey conducted between January and May to assess consumer experiences with their provider and health plan, received by a random sample of patients. We use the results to measure our performance against our goals and determine the effectiveness of actions implemented to improve.

 

2021 NCQA Health Plan Star Rating
Survey Measures	2021 Rate	2021 All Affiliates Child Medicaid Average	2020 NCQA Quality Compass® National Average (All LOB)
Getting Care
Getting Needed Care Composite (% Always or Usually)	82.10%	86.49%	86.03%
Ease of Getting Needed Care (% Always or Usually)	88.11%	90.65%	91.23%
Ease of Seeing a Specialist (% Always or Usually)	76.09%	82.33%	79.77%
Getting Care Quickly Composite (% Always or Usually)	80.10%	87.66%	90.53%
Ease of Getting Urgent Care (% Always or Usually)	87.23%	91.59%	92.58%
Ease of Getting a Check-Up or Routine Care (% Always or Usually)	72.96%	83.73%	88.97%
Satisfaction with Plan Physicians
Rating of Personal Doctor (% 9 or 10)	72.02%	77.46%	78.57%
Rating of Specialist Seen Most Often (% 9 or 10)	74.42%	74.27%	73.36%
Rating of All Healthcare (% 9 or 10)	66.80%	73.02%	71.92%
Coordination of Care (Always or Usually)	87.62%	85.25%	86.08%
Satisfaction with Plan Services
Rating of Health Plan (% 9 or 10)	62.05%	70.06%	71.90%

Providers directly affect over half of the questions used for scoring. Empire BlueCross BlueShield HealthPlus offers an online course for providers and office staff designed to teach how to improve communication skills, build patient trust and commitment, and expand your knowledge of the CAHPS Survey. The Improving the Patient Experience course is available at no cost and is eligible for one continuing medical education (CME) credit by the American Academy of Family Physicians. Providers can access the course at https://www.mydiversepatients.com/le-ptexp.html.

 

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

 

NYE-NU-0385-21 November 2021

 

Please continue to check Medicaid Provider Communications & Updates at www.empireblue.com/nymedicaiddoc for the latest Medicaid information including:

• AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines
  update
• Prior authorization updates for medications billed under the medical
  benefit

We want to provide you with an update regarding the new effective date for the NYC Medicare Advantage Plus offering for The City of New York retirees.

 

On April 1, 2022, more than 200,000 Medicare-eligible City of New York retirees will transition to the NYC Medicare Advantage Plus Plan offered by an alliance between Empire BlueCross BlueShield (Empire) and EmblemHealth.

 

The NYC Medicare Advantage Plus Plan is a Medicare Advantage PPO plan that allows retirees to receive services from both in-network and out-of-network providers. Out-of-network providers must be eligible to receive Medicare payment. Under this new plan, City of New York retirees will have no difference in cost share for both in-network and out-of-network services. The NYC Medicare Advantage Plus Plan offers the same hospital and medical benefits that original Medicare covers, as well as additional benefits that original Medicare does not provide, such as an annual routine physical exam, hearing exams, health and fitness tracking, LiveHealth Online,* and SilverSneakers®.*

 

Are you in-network? If you are contracted with any of the following networks, you are already an
in-network provider participating in this plan. You should continue to see your City of New York retiree patients and submit claims to Empire or your local BlueCross BlueShield plan:

• EmblemHealth’s Medicare Choice PPO
• Empire MediBlue PPO
• BlueCross BlueShield (BCBS) Medicare Advantage PPO Network

Are you out-of-network? No problem, you can see City of New York retirees and will still get paid 100% of the Medicare Allowed rate. No contract required.

• You can continue seeing our members as long as you are eligible to receive payments from Medicare.
• Your reimbursement is the same as under Original Medicare.
• Our members are not required to obtain a referral before they see a provider.

 

Please take advantage of our upcoming provider webinar to help you better understand these upcoming changes. Registration link: https://bit.ly/2Y9DrBj

 

* LiveHealth Online is an independent company providing telehealth services on behalf of the Alliance, an alliance between Empire BlueCross BlueShield (Empire) and EmblemHealth. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of the Alliance, an alliance between Empire BlueCross BlueShield (Empire) and EmblemHealth.

 

EBMCRNU-0001-21 December 2021

 

Effective January 1, 2022, IngenioRx/CVS Specialty Pharmacy* will no longer distribute the brand name drug Botox^®. However, Botox will still be available to Empire BlueCross BlueShield members through other vendors.

 

Please note:

• This is not a change in member benefits. This is a change in the Botox vendor only.
• If the member is not using IngenioRx/CVS Specialty Pharmacy to obtain Botox, no action is needed.

             

For Botox managed under a Medicare member’s part B (medical) benefit

Providers should be using buy and bill for any Medicare member who currently receive Botox through their part B (medical) benefit.  If your patient is receiving Botox using their part B benefit and is receiving their prescription from IngenioRx/CVS Specialty pharmacy, effective January 1, 2022, IngenioRx/CVS Specialty will no longer filled the prescription. As of January 1, 2022, you will need to buy this drug and bill your patient’s health plan.

 

If you have questions regarding a Medicare member’s part B benefits, call Provider Services using the information on the back of the member’s ID card.

 

For Botox managed under a Medicare member’s part D (pharmacy) benefit

Effective January 1, 2022, Medicare members who currently receive Botox through IngenioRx/CVS Specialty Pharmacy using their part D (pharmacy) benefit must change to another in-network specialty or retail pharmacy that can obtain and dispense Botox.

 

If you have questions regarding a Medicare member’s part D benefit, call Pharmacy Member Services using the information on the back of the member’s ID card.

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Empire BlueCross BlueShield. CVS is an independent company providing pharmacy services on behalf of Empire BlueCross BlueShield.

 

EBSCRNU-0112-21 November 2021

 

Effective January 1, 2022, the Local 282 Welfare Trust Fund, NY will offer an Empire MediBlue Freedom (PPO) Medical plan. Empire BlueCross BlueShield (Empire) Retiree Solutions will provide medical benefits for the Local 282 Welfare Trust Fund retirees through Empire’s Preferred Provider Organization (PPO) product, which includes the National Access Plus benefit. The PPO plan allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

 

Local 282 Welfare Trust Fund members’ copay or coinsurance percentage will be the same whether their provider is in- or out-of-network. Locally or nationwide, doctors or hospitals, member share-of-cost (SOC) does not change.

 

Noncontracted providers may continue treating Local 282 Welfare Trust Fund members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member SOC.

 

The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers, while covering additional benefits that Medicare does not, such as LiveHealth Online* and SilverSneakers.*

 

The prefix on the Medicare Advantage ID cards is XLU.

 

Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool on the Availity* Portal at https://www.availity.com.

 

Providers will follow their normal claim filing procedures for Local 282 Welfare Trust Fund member claims.

 

Providers may call the number on the back of the member’s ID card for eligibility, prior authorization requirements and any questions about the Local 282 Welfare Trust Fund member benefits or coverage.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Empire BlueCross BlueShield. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Empire BlueCross BlueShield.

 

EBSCRNU-0215-21 November 2021

 

Effective December 1, 2021, Empire BlueCross BlueShield (Empire) will prefer the referring physician name and NPI to be included on professional claims for home infusion therapy (HIT) services in fields 17 and 17a on the CMS-1500 Claim Form.

 

Providers should report the referring physician information in accordance with the Empire guidelines in the Electronic Data Interchange (EDI) Companion Guide for claims submitted electronically.

 

Thank you for your assistance in our ongoing efforts to promote accurate claims processing and payment. We continue to be dedicated to delivering access to quality care for our members, providing higher value to our customers, and helping improve the health of our communities.

 

If you have questions regarding this process, contact your Network Manager.

 

EBSCRNU-0211-21 November 2021

 

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

The HEDIS^® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality health-care services. 

 

The ECDS Reporting Standard provides a method to collect, and report structured electronic clinical data for HEDIS quality measurement and improvement. 

 

Benefits to providers:

• Reduced burden of medical record review for quality reporting
• Improved health outcomes and care quality due to greater insights for more specific patient-centered care

 

ECDS reporting is part of the National Committee for Quality Assurance’s (NCQA) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures. 

 

Learn more about NCQA’s digital quality system and what it means to you and your practice, at the following link: https://www.ncqa.org/hedis/the-future-of-hedis/hedis-electronic-clinical-data-system-ecds-reporting/.

 

ECDS measures

The first publicly reported measure using the HEDIS ECDS Reporting Standard is the Prenatal Immunization Status (PRS) measure.  In 2022, NCQA will include the PRS measure in Health Plan Ratings for Medicaid and Commercial plans for measurement year 2021.

 

For HEDIS measurement year 2022, the following measures can be reported using ECDS: 

• Childhood Immunization Status (CIS-E)*
• Immunizations for Adolescents (IMA-E)*
• Breast Cancer Screening (BCS-E)
• Colorectal Cancer Screening (COL-E)
• Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)*
• Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
• Depression Remission or Response for Adolescents and Adults (DRR-E)
• Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
• Adult Immunization Status (AIS-E)
• Prenatal Immunization Status (PRS-E) (Accreditation measure for 2021)
• Prenatal Depression Screening and Follow-Up (PND-E)
• Postpartum Depression Screening and Follow-Up (PDS-E)

 

* Indicates that this is the first year that the measure can be reported using ECDS

Of note, NCQA added the ECDS reporting method to three existing HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening and Follow-up Care for Children Prescribed ADHD Medication. Initially, the ECDS method will be optional which provides health plans an opportunity to try out reporting using the ECDS method before it is required to transition to ECDS only in the future.

 

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

 

NYE-NU-0384-21 November 2021

 

Please continue to read news and updates at empireblue.com/medicareprovider for the latest Medicare Advantage information, including:

• Medical step therapy updates
• Empire BlueCross expands specialty pharmacy precertification list
• AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines
  update