January 2024 Provider Newsletter

There is no action needed by our care providers. There will be no changes to your agreements or contract, reimbursement, or level of support — now or in the future — because of our new name. For members, our new name will not cause any reduction to coverage or access to care.

For more information, please refer to these Frequently Asked Questions or go to https://anthem.com/provider. You can also contact your Provider Services representative.

We look forward to continuing to provide our members with the strong medical coverage and healthcare assistance they expect and deserve.

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Medicare services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC., or Anthem Blue Cross and Blue Shield Retiree Solutions, trade name of Anthem Insurance Companies, Inc.
Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CDCRCM-046792-23-CPN46560, NYBCBS-CDCRCM-055644-24

AdministrativeCommercialJanuary 1, 2024

Important Changes for Active Members of Northrop Grumman Corporation

Effective January 1, 2024, Northrop Grumman Corporation will contract with Quantum Health to perform healthcare navigation and care coordination services for their active member population only. As part of this contract, Quantum Health will support member healthcare and benefit needs, including member and care provider services and medical utilization review and submission to Anthem. Northrup Grumman Corporation active members may be identified by the group number beginning with 174022 on the member ID card. A sample ID card is below.

Anthem will remain responsible for claims adjudication and certain services as described below. Anthem will also remain the administrator of Behavioral Health Utilization Management, inclusive of retrospective reviews, and Case Management.

Quantum Health is the point of contact for member and care provider inquiries.

Quantum Health will be the point of contact for members and healthcare providers to verify:

Benefit coverage information.
Eligibility inquiries.
Prior-authorization submission and review (as stated above).

You will find Quantum Health’s contact information on the back of the new member ID cards distributed to members. A sample of the card is provided below.

Anthem will remain the point of contact for care providers for the following:

Behavioral Health Utilization Management, inclusive of retrospective reviews and Case Management.
Quantum Health will redirect care provider questions/inquiries to Anthem or local Blue for Medical and Behavioral Health Services for the following:
- Provider contracting
- Remittances
- Fee schedule
- Value-Based Programs
- Network status
- Demographic information updates

Sample member ID card

Based on the information outlined above, there is a change in the Member Services and Provider Services/pre-certification phone numbers. These two new phone numbers are located on the back of the Medical Member ID card.

If you have any questions, please contact your provider relationship management representative. We are committed to a future of shared success.

Commercial services provided by Anthem Blue Cross, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BC-CM-047192-23

AdministrativeCommercialJanuary 1, 2024

Using and billing air ambulance services appropriately

When using or billing air ambulance services, please remember:

To facilitate timely and accurate claim processing of air ambulance services, include the facility’s record (emergency department record, or if an inpatient, the discharge or transfer summary) along with your run sheet. Providing this information will greatly facilitate timely review of medical necessity.
Regarding the practice of using air ambulance services solely because use of ground transport would temporarily deplete local area Emergency Medical Services (EMS) availability, while EMS availability is always a local EMS concern, please understand that this reason alone does not meet medical necessity criteria for our members.
Lastly, excess miles flown to keep a patient within the sending facility’s health system, when another closer capable receiving hospital has capacity, does not meet medical necessity criteria. Determination of medical necessity, including mode of transportation, is determined in accordance with Anthem’s clinical guidelines and medical necessity criteria. These determining guidelines include only approving the distance to the closest capable facility with capacity.

Taking the above into consideration will result in faster processing and lower denials of your air ambulance service claims. For your reference, see CG-ANC-04 Ambulance Services: Air and Water.

If you have questions, contact your local provider relationship management representative.

We look forward to working together to achieve improved outcomes.

Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-047454-23-CPN47431

AdministrativeCommercialJanuary 1, 2024

Specialty pharmacy site of care reviews for NYSHIP Empire Plan members

Effective July 1, 2023, specialty pharmacy site of care reviews are required for New York State Health Insurance Program (NYSHIP) Empire Plan members. NYSHIP Empire Plan members are billed under the dedicated prefix YLS. Anthem administers the Empire Plan Hospital Program. Pre-determination clinical review of non-oncology use of specialty pharmacy drugs is managed by the clinical team dedicated to NYSHIP Empire Plan members:

Important note: Currently your NYSHIP Empire Plan patients may receive infusions of these medications without a predetermination of benefits. As of July 1, 2023, it is strongly recommended you request a predetermination of benefits for your patients’ continued infusions of these medications. Access our Clinical Criteria to view the complete information for these predetermination requests.

Effective for dates of service on and after July 1, 2023, the specialty pharmacy codes from current or new clinical criteria documents are included in our site of care review process. Drugs excluded from our site of care review process include oncology drugs, drugs used to treat hemophilia, and injectables.

Access the NYSHIP Empire Plan Site of Care Drug List to view the complete information for these site of care updates and to view the complete list of drugs subject to site of care review.

With your help, we can continually build towards a future of shared success.

NYBCBS-CM-047243-23

AdministrativeMedicaidDecember 15, 2023

Managed Long-Term Care office is moving

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

We are pleased to inform you that our office at 1981 Marcus Avenue, Lake Success, New York, will soon be moving! On December 18, 2023, our new address will be 1985 Marcus Avenue, Suite 150, Lake Success, NY 11042 (located right across the parking lot).

Please update your records with this information and starting December 18, 2023, use our new mailing address for all correspondence.

If you have any questions, please contact our Health Care Networks team at 929-946-6500 or Providerrelations@empireblue.com or your designated account manager.

We are excited for genuine collaboration with you, our care provider partners.

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.

NYBCBS-CD-047357-23

AdministrativeCommercialJanuary 1, 2024

CAA: Maintain your online provider directory information

Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed.

Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. Online update options include:

Adding/changing an address location.
Changing a name.
Changing a phone/fax number.
Provider leaving a group or a single location.
Closing a practice location.

The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information helps us ensure your online provider directory information is current.

MULTI-BCBS-CM-047108-23

AdministrativeCommercialJanuary 1, 2024

Enhanced outpatient facility editing for National Correct Coding Initiative Medically Unlikely Edits

Beginning with claims processed on and after February 17, 2024, we will update our claims editing process for outpatient facility claims by applying the Medicare National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs). NCCI edits are guidelines developed by the Centers for Medicare & Medicaid Services (CMS) to promote national correct coding based on industry standards for current coding practices.

These edits provide an opportunity to shift certain existing back-end reviews to front-end adjudication for outpatient facility claims. While this may facilitate quicker claim adjudication, it may also cause claims to deny frequency unit limits tied to MUEs if correct coding guidelines are not followed. For additional information, visit CMS.gov and select the Medically Unlikely Edits page.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

NYBCBS-CM-045943-23

AdministrativeMedicare AdvantageJanuary 1, 2024

Inappropriate primary diagnosis

According to ICD-10-CM guidelines for coding and reporting, it is inappropriate to bill certain diagnosis codes as a primary or first listed diagnosis. Instead, these codes should always be sequenced as a secondary or subsequent diagnosis. Effective for claims processed on or after April 1, 2024, Empire BlueCross BlueShield will apply these correct coding ICD-10-CM guidelines and deny:

Professional claims submitted on a CMS-1500 form that report inappropriate primary diagnosis codes as the only diagnosis on the claim or claim line; and facility claims submitted on a CMS-1450 form that report inappropriate primary diagnosis codes as the principal diagnosis or only code on the claim.

As provided by ICD-10-CM guidelines, inappropriate primary diagnosis codes include but are not limited to:

External Cause Codes of Morbidity (V, W, X, or Y codes [ICD-10-CM]) describes an environmental event causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. These codes are intended to be supplemental to the principal or primary diagnosis code indicating the nature of the condition. In addition, based on this guideline, a diagnosis code of external causes cannot be the only diagnosis on the claim.
Manifestation Codes: Certain conditions contain both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD Manual coding guidelines have established a coding convention that requires the underlying condition to be sequenced first followed by the manifestation. According to the ICD Manual coding guidelines, the primary, first listed, or principal diagnosis cannot be a manifestation code. In addition, based on this guideline, a manifestation code cannot be the only diagnosis on the claim.
Sequela Codes: a sequela (7th character "S") code cannot be listed as the primary, first listed, or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code. In addition, based on this guideline, a sequela (7th character "S") code cannot be the only diagnosis on a claim.
Secondary Diagnosis: According to ICD guidelines, a secondary diagnosis code can only be used as a secondary diagnosis. Since these codes are only for use as supplemental codes, any procedure or service received with a secondary diagnosis code as the principal or primary diagnosis will be denied as incorrectly coded.

EOB Message: We denied this service since it was reported incorrectly. Per CMS (Federal) correct coding guidelines, specific Supplementary Classification ICD-10 codes cannot be used as the primary diagnosis or as the only diagnosis on the claim.

Ex-Codes: 00V16 and v16

If you have questions about this communication or need assistance, contact Provider Services by calling the number on the back of your patient’s member ID card.

Medicare services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC., or Anthem Blue Cross and Blue Shield Retiree Solutions, trade name of Anthem Insurance Companies, Inc.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CR-035108-23-CPN34788

AdministrativeMedicaidJanuary 1, 2024

Inappropriate primary diagnosis

According to ICD-10-CM guidelines for coding and reporting, it is inappropriate to bill certain diagnosis codes as a primary or first listed diagnosis. Instead, these codes should always be sequenced as a secondary or subsequent diagnosis. Effective for claims processed on or after February 1, 2024, Empire BlueCross BlueShield HealthPlus will apply these correct coding ICD-10-CM guidelines and deny:

Professional claims submitted on a CMS-1500 form that report inappropriate primary diagnosis codes as the only diagnosis on the claim or claim line; and facility claims submitted on a CMS-1450 form that report inappropriate primary diagnosis codes as the principal diagnosis or only code on the claim.

As provided by ICD-10-CM guidelines, inappropriate primary diagnosis codes include but are not limited to:

External Cause Codes of Morbidity (V, W, X, or Y codes [ICD-10-CM]) describes an environmental event causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. These codes are intended to be supplemental to the principal or primary diagnosis code indicating the nature of the condition. In addition, based on this guideline, a diagnosis code of external causes cannot be the only diagnosis on the claim.
Manifestation Codes: Certain conditions contain both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD Manual coding guidelines have established a coding convention that requires the underlying condition to be sequenced first followed by the manifestation. According to the ICD Manual coding guidelines, the primary, first listed, or principal diagnosis cannot be a manifestation code. In addition, based on this guideline, a manifestation code cannot be the only diagnosis on the claim.
Sequela Codes: a sequela (7th character "S") code cannot be listed as the primary, first listed, or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code. In addition, based on this guideline, a sequela (7th character "S") code cannot be the only diagnosis on a claim.
Secondary Diagnosis: According to ICD guidelines, a secondary diagnosis code can only be used as a secondary diagnosis. Since these codes are only for use as supplemental codes, any procedure or service received with a secondary diagnosis code as the principal or primary diagnosis will be denied as incorrectly coded.

Ex-Codes: 00V16 and v16

If you have questions about this communication or need assistance, contact Provider Services at 800-450-8753.

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CD-035107-23-CPN34788

Digital SolutionsCommercialDecember 26, 2023

Training for digital requests for additional information (Digital RFAI)

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

Now accepting Medicaid and Medicare member claims

As a care provider taking advantage of digital requests for additional information (Digital RFAI), you know it is the most efficient way to send the required documentation to process your Commercial member claims. As of mid-November, you also can receive Digital RFAI notifications for your Medicaid and Medicare member claims.

The process will not change for Medicaid and Medicare member claims. You will still follow the same fast and easy process for our Medicaid and Medicare member claims as you do for your commercial member claims. The only change is that your Medicaid and Medicare member claims will not pend. Medicaid and Medicare member claims will deny when additional documentation is needed to process the claim.

Notifications will remain on your dashboard for up to 30 days as they do today. Submit the documentation at your convenience (most care providers submit documents within seven to 14 days).

Your notifications will continue to arrive on your dashboard each morning, making it convenient to plan your work; no need to check your dashboard throughout the day.

Learn more!

In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration:

Date	Time
January 23, 2024	2:30 to 3:45 p.m. ET

Availity administrators can use this link to register for live training or to view the training on demand.

For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient:

Date	Time
January 23, 2024	2:30 to 3:30 p.m. ET

Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training, or to view the live training on-demand.

Contact Availity Customer Support at availity.com/Contact-Us or your provider relationship representative if you have any questions.

Not a Digital RFAI care provider?

If you’re not already using the Digital RFAI process and want to take advantage of faster claims processing, participation is easy.

Registration

The organization’s Availity administrator will register for Medical Attachments, which enables care provider organizations to receive notices from the payer and submit requested documents digitally.

All billing NPIs/TINs must be registered.

User roles

The Availity administrator will be required to update or add new users with these specific role assignments through Availity:

Claims Status
Medical Attachments

Enable users to view the Availity Attachment Dashboard.

Ready to go!

After the registration and user roles are completed on Availity, the Digital RFAI process is ready.

Requests will automatically appear on the Attachments Dashboard each morning (when documents are needed).

We are committed to finding solutions that help our care provider partners offer quality services to our members.

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

NYBCBS-CM-047946-23-CPN47121

Digital SolutionsCommercialDecember 1, 2023

Maximize accuracy, efficiency, and patient satisfaction with helpful resources

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

Making the Claims Process Work for You — a short on-demand video and step-by-step guide

Timely and accurate submission of claims plays a crucial role in a healthcare provider’s revenue management, operational efficiency, and patient satisfaction. As your trusted partner in health, we are committed to providing you and your staff with the resources you need to help make delivering quality care easier.

Watch this short on-demand video and step-by-step guide to help you submit a claim correctly the first time, reduce duplicate claims and common submission errors, and properly submit corrected claims resulting in faster payments, less rework, and happier patients.

Watch the quick training video and download the guide and learn how to:

Get it right the first time and proactively reduce denied and duplicate claims.
Properly submit a corrected claim through Availity Essentials using the correct frequency code.
Properly submit claims using electronic data interchange (EDI), including useful tips for your clearinghouses and vendors.
Understand role requirements.

Start improving claims processing for your practice: Access your on-demand video and step-by-step guide now.

NYBCBS-CM-045308-23-CPN44893, NYBCBS-CM-047949-23-CPN47295

Education & TrainingCommercialJanuary 1, 2024

Important information about your Anthem patients’ specialty prescriptions

Effective January 1, 2024, most specialty prescriptions will transfer to BioPlus, CarelonRx specialty pharmacy that services Anthem members. This migration is taking place in multiple waves throughout the next year.

What happens next?

If you have patients affected by this pharmacy change, BioPlus will contact you to request new prescriptions, refills, or prior authorizations. You will also receive a letter from CarelonRx.
Current specialty prescriptions with open refills will automatically transfer to BioPlus.
Impacted patients will receive a letter and a phone call, explaining this transition.
There is nothing you or your patients need to do except speak with BioPlus when they call.

What is the benefit to you and your patients?

CarelonRx and BioPlus work together to deliver patients an unparalleled level of high-tech, high-touch service that focuses on their whole health.

As a care provider, you will receive fast and easy benefit confirmation and prior authorizations for expedited time to therapy. BioPlus also offers comprehensive infusion services that include dedicated nurse concierges, patient advocates, and disease-specific education and clinical reminders.

If you have any questions, please call your Anthem representative. We’re here to help.

CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.

MULTI-BCBS-CM-047443-23-CPN47164

Education & TrainingMedicaidJanuary 1, 2024

Provider Pathways — Learn all about it

Empire BlueCross BlueShield HealthPlus (Empire) wants to remind you of a training resource that’s available for all providers. It’s called Provider Pathways, an on-demand digital eLearning that’s comprised of a collection of topics called modules. Each module covers a different aspect of doing business with Empire. Depending on what you need, you can take one or all the modules.

How to find Provider Pathways

Provider Pathways — Doing Business with eLearning for Empire, gives you the flexibility for scheduling training for yourself and your staff. You can find this training on the provider website:

Go to https://providerpublic.empireblue.com
Select Training Academy under Resources in the top navigation.
Once on the site, select Provider Pathways under Training Resources.

If you have questions about this provider resource, please reach out to your Healthcare Networks team.

Refer to attachment to view full details

NYBCBS-CD-043774-23-CPN40326

ATTACHMENTS (available on web): Provider Pathways — Learn all about it (pdf - 0.27mb)

Education & TrainingMedicaidMarch 31, 2023

Ready, set, renew!

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

It’s time for some of your patients to renew their Medicaid benefits. As New York begins to recommence Medicaid renewals, we want to ensure you have the information needed to help your Medicaid patients renew their healthcare coverage. Some patients have never had to renew their coverage at all, while other patients may have forgotten the process entirely.

We’re here to help.

What steps do my patients need to take?

Ready: Patient gets their documents ready, either online or by mail.
Set: Patient ensures their information is accurate.
Renew: Patient completes renewal:
- Via web: ny.gov
- Via phone: Call Empire BlueCross BlueShield HealthPlus at 888-809-8009 (TTY 711)
- Via mail: Paper Renewals (HRA/LDSS only):
  - Patients can use pre-paid envelope provided by state.
  - If envelope is misplaced, please call 888-809-8009.

What if I need assistance?

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials,* go to availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.

NYBCBS-CD-017956-22-CPN16407, NYBCBS-CD-047503-23-CPN047298, NYBCBS-CD-056727-24-CPN56608

Education & TrainingMedicaidNovember 30, 2023

CPT Category II update

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

Care providers can earn additional reimbursement on health and wellness services provided to Empire BlueCross BlueShield HealthPlus (Empire) members. Empire is offering reimbursement for the use of CPT^® Category II codes to encourage continued improvements in member care. The use of CPT Category II codes benefits the healthcare system by providing more specific information about healthcare encounters, such as how data can be used to help Empire care providers work more efficiently and effectively in the best interest of each member.

Refer to attachment to view full details.

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.

NYBCBS-CD-046501-23

ATTACHMENTS (available on web): CPT Category II update (pdf - 0.19mb)

Medical Policy & Clinical GuidelinesMedicare AdvantageDecember 1, 2023

Clinical Criteria updates — August 2023

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

On August 18, 2023, and August 30, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield (Empire). These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

New: newly published criteria
Revised: addition or removal of medical necessity requirements, new document number
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Note:

The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
This notice is meant to inform the provider of new or revised criteria that has been adopted by Empire only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date	Clinical Criteria number	Clinical Criteria title	New or revised
January 8, 2024	*CC-0244	Columvi (glofitamab-gxbm)	New
January 8, 2024	*CC-0245	Izervay (avacincaptad pegol)	New
January 8, 2024	*CC-0246	Rystiggo (rozanolixizumab-noli)	New
January 8, 2024	*CC-0247	Beyfortus (nirsevimab)	New
January 8, 2024	CC-0001	Erythropoiesis Stimulating Agents	Revised
January 8, 2024	CC-0124	Keytruda (pembrolizumab)	Revised
January 8, 2024	CC-0104	Levoleucovorin Agents	Revised
January 8, 2024	CC-0100	Romidepsin	Revised
January 8, 2024	*CC-0182	Iron Agents	Revised
January 8, 2024	CC-0075	Rituximab Agents for Non-Oncologic Indications	Revised
January 8, 2024	CC-0176	Beleodaq (belinostat)	Revised
January 8, 2024	CC-0180	Monjuvi (tafasitamab-cxix)	Revised
January 8, 2024	CC-0107	Bevacizumab for non-ophthalmologic indications	Revised
January 8, 2024	CC-0216	Opdualag (nivolumab and relatlimab-rmbw)	Revised
January 8, 2024	CC-0196	Zynlonta (loncastuximab tesirine-lpyl)	Revised
January 8, 2024	CC-0197	Jemperli (dostarlimab-gxly)	Revised
January 8, 2024	CC-0203	Ryplazim (plasminogen, human-tvmh)	Revised
January 8, 2024	CC-0193	Evkeeza (evinacumab)	Revised
January 8, 2024	*CC-0034	Hereditary Angioedema Agents	Revised
January 8, 2024	*CC-0041	Complement Inhibitors	Revised
January 8, 2024	*CC-0207	Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)	Revised
January 8, 2024	CC-0028	Benlysta (belimumab)	Revised
January 8, 2024	*CC-0243	Vyjuvek (beremagene geperpavec)	Revised
January 8, 2024	CC-0165	Trodelvy (sacituzumab govitecan)	Revised
January 8, 2024	*CC-0125	Opdivo (nivolumab)	Revised
January 8, 2024	*CC-0119	Yervoy (ipilimumab)	Revised
January 8, 2024	CC-0143	Polivy (polatuzumab vedotin-piiq)	Revised
January 8, 2024	*CC-0072	Vascular Endothelial Growth Factor (VEGF) Inhibitors	Revised

Services provided by Empire HealthChoice HMO, Inc., Empire HealthChoice Assurance, Inc., or Empire BlueCross BlueShield Retiree Solutions. Empire BlueCross BlueShield Retiree Solutions is the trade name of Anthem Insurance Companies, Inc. lndependent licensees of the Blue Cross Blue Shield Association, an association of independent Blue Cross Blue Shield plans.

NYBCBS-CR-044420-23-CPN44137

Medical Policy & Clinical GuidelinesMedicaidDecember 4, 2023

Clinical Criteria updates — August 2023

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

Summary: On May 19, 2023, August 18, 2023, and August 30, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus (Empire). These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

New: Newly published criteria
Revised: Addition or removal of medical necessity requirements, new document number
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

Please share this notice with other providers in your practice and office staff.

Please note:

The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
This notice is meant to inform the provider of new or revised criteria that has been adopted by Empire only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date	*Clinical Criteria* number	*Clinical Criteria* title	New or revised
January 11, 2024	*CC-0244	Columvi (glofitamab-gxbm)	New
January 11, 2024	*CC-0245	Izervay (avacincaptad pegol)	New
January 11, 2024	*CC-0246	Rystiggo (rozanolixizumab-noli)	New
January 11, 2024	*CC-0247	Beyfortus (nirsevimab)	New
January 11, 2024	CC-0001	Erythropoiesis Stimulating Agents	Revised
January 11, 2024	CC-0124	Keytruda (pembrolizumab)	Revised
January 11, 2024	CC-0104	Levoleucovorin Agents	Revised
January 11, 2024	CC-0100	Romidepsin	Revised
January 11, 2024	*CC-0182	Iron Agents	Revised
January 11, 2024	CC-0075	Rituximab Agents for Non-Oncologic Indications	Revised
January 11, 2024	CC-0176	Beleodaq (belinostat)	Revised
January 11, 2024	CC-0180	Monjuvi (tafasitamab-cxix)	Revised
January 11, 2024	CC-0107	Bevacizumab for non-ophthalmologic indications	Revised
January 11, 2024	CC-0216	Opdualag (nivolumab and relatlimab-rmbw)	Revised
January 11, 2024	CC-0196	Zynlonta (loncastuximab tesirine-lpyl)	Revised
January 11, 2024	CC-0197	Jemperli (dostarlimab-gxly)	Revised
January 11, 2024	CC-0203	Ryplazim (plasminogen, human-tvmh)	Revised
January 11, 2024	CC-0193	Evkeeza (evinacumab)	Revised
January 11, 2024	*CC-0034	Hereditary Angioedema Agents	Revised
January 11, 2024	*CC-0041	Complement Inhibitors	Revised
January 11, 2024	*CC-0207	Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)	Revised
January 11, 2024	CC-0028	Benlysta (belimumab)	Revised
January 11, 2024	*CC-0243	Vyjuvek (beremagene geperpavec)	Revised
January 11, 2024	CC-0165	Trodelvy (sacituzumab govitecan)	Revised
January 11, 2024	*CC-0125	Opdivo (nivolumab)	Revised
January 11, 2024	*CC-0119	Yervoy (ipilimumab)	Revised
January 11, 2024	CC-0143	Polivy (polatuzumab vedotin-piiq)	Revised
January 11, 2024	*CC-0072	Vascular Endothelial Growth Factor (VEGF) Inhibitors	Revised
January 11, 2024	*CC-0002	Colony Stimulating Factor Agents	Revised

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.

NYBCBS-CD-044610-23-CPN44139

Medical Policy & Clinical GuidelinesMedicare AdvantageJanuary 1, 2024

Genetic testing code list update

Effective for dates of service on and after April 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

CPT^® code	Description
0378U	RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab
0364U	Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate
0380U	Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and phenotype
0130U	Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure)
0131U	Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure)
0132U	Hereditary ovarian cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure)
0134U	Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure)
0135U	Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure)
0379U	Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop
0329U	Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite insta
0287U	Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict
0392U	Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an
0022U	Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider
0179U	Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s)
0239U	Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations
0326U	Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number a
0333U	Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement
0368U	Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4,
0388U	Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct
0391U	Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti
0397U	Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, del
0400U	Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie
0401U	Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a

As a reminder, ordering and servicing care providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

Access the Carelon Medical Benefits Management ProviderPortal_SM directly at providerportal.com:

Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

Access Carelon Medical Benefits Management via Availity Essentials at Availity.com.

For questions related to guidelines, please contact via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

NYBCBS-CR-041250-23-CPN40788

Medical Policy & Clinical GuidelinesCommercialJanuary 1, 2024

Carelon Medical Benefits Management, Inc. genetic testing CPT^® code list update

Effective for dates of service on and after April 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

CPT code	Description
0378U	RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab
0364U	Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate
0380U	Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and phenotype
0130U	Hereditary colon cancer disorders (such as Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in
0131U	Hereditary breast cancer-related disorders (such as hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure)
0132U	Hereditary ovarian cancer-related disorders (such as, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure)
0134U	Hereditary pan cancer (such as, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure)
0135U	Hereditary gynecological cancer (such as, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure)
0379U	Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop
0329U	Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite insta
0287U	Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict
0392U	Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an
0022U	Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider
0179U	Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s)
0242U	Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements
0326U	Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number
0333U	Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement
0388U	Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct
0391U	Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti
0397U	Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, del
0400U	Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie
0401U	Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in [one] of the following ways:

Access Carelon’s ProviderPortal_SM directly at providerportal.com:
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
Access Carelon Medical Benefits Management via the Availity platform at Availity.com.

For questions related to guidelines, please contact Carelon Medical benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

NYBCBS-CM-041129-23-CPN40786

Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageMedicaidDecember 28, 2023

Transition to Carelon Medical Benefits Management, Inc. cardiology guidelines

Effective April 1, 2024, requested cardiology interventions will be transitioned to the following Carelon Medical Benefits Management, Inc. guidelines for medical necessity/clinical appropriateness reviews. Applicable CPT^® codes lists are included in each guideline linked below:

Preapproval requirements remain the same. The requested services received on or after April 1, 2024, will be reviewed with the new Clinical Criteria.

As a reminder, ordering and servicing care providers may submit preapproval requests to Carelon Medical Benefits Management using the ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

NYBCBS-CDCRCM-042156-23-CPN41724

Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageMedicaidJanuary 1, 2024

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

This article was updated on May 9, 2024.

Effective for dates of service on and after April 14, 2024, the following updates apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Radiology

Imaging of the heart

Cardiac CT
Cardiomyopathy: Added specificity to establish the basis for the suspicion of ARVD. This change aligns with Cardiac MRI guidelines.

Resting Transthoracic Echocardiography (TTE)
Evaluation of ventricular function: New indications for evaluation of patients on mavacamten for treatment of HOCM

Imaging of the abdomen and pelvis
Biliary tract dilatation or obstruction: Added indication for annual surveillance in Caroli disease/syndrome based on a 2022 guideline recommendation.

Diffuse liver disease: Removed indication for LiverMultiScan in hemochromatosis as there is insufficient evidence that this provides an advantage over standard MRI for this condition

Osteomyelitis: Added requirement for initial evaluation with radiographs in adult patients based on ACR appropriateness criteria.

Septic arthritis: Added requirement for initial radiographs in adult patients based on ACR appropriateness criteria Pancreatic mass, indeterminate cystic (IPMN/IPMT): For enlarging lesions in patients age 80 or greater, increased surveillance frequency to annually and removed endpoint of 4 years.

Pelvic floor disorders: Added indication for MRI (MR defecography preferred) in suspected pelvic organ prolapse based on ACR appropriateness criteria

Transplant-related imaging: Added indication for single CT abdomen or abdomen/pelvis prior to lung, kidney, or stem cell transplant to align with CT chest guidelines.

Imaging of the brain

Movement disorders (Adult only): Added indication for CT head for assessment of skull density prior to MRgFUS for essential tremor

Trauma: Added a 3-6 week follow up study in patients age 6 or younger with stable or inconclusive exam, due to difficulty in accurately assessing for changes in neurologic status
Acoustic neuroma: Added long-term follow-up intervals based on specialty society guidelines

Imaging of the chest

Perioperative or periprocedural evaluation, not otherwise specified
Added indication for CT chest to be used for planning of biopsy or placement of fiducial markers using navigational bronchoscopy

Imaging of the head and neck

Acoustic neuroma: Added long-term follow-up intervals based on specialty society guidelines
Localized facial pain (including trigeminal neuralgia): Added MRI orbit/face/neck for this indication based on ACR criteria; some facilities use MRI face rather than brain for this condition

Oncologic imaging

Cancer screening

Breast cancer screening:
Addition of high-risk genetic mutations (NCCN alignment citing absolute risk of 20% or greater)

Lung cancer screening: Clarification of asbestos-related lung disease as risk factor independent of smoking, aligned with original intent.

Pancreatic cancer screening:
Alignment with NCCN recommended parameters; changes are overall expansive, except for:
Older start age (from 45 to 50) for certain genes (ATM, BRCA1, BRCA2, MLH1, MSH2, MSH6, EPCAM, PALB2, TP53)
Family history alone (relative requirement)

Breast cancer
CT chest, CT abdomen and pelvis: Added diagnostic workup allowance when metastatic disease is clinically suspected at presentation

MRI breast: Addition/clarification of surveillance scenarios aligned with NCCN/ACR considerations
FDG-PET/CT: Added allowance for RT planning locoregional recurrence (for example, confirmation of regional nodal involvement)
18F-fluoroestradiol (18F-FES) PET/CT: Added that it Is not indicated due to uncertain net benefit; low-level evidence, insufficient data on outcomes.

Cervical cancer
FDG-PET/CT: Update for follow-up of disease treated with either adjuvant RT or chemoradiation (NCCN alignment).

Hepatocellular and biliary tract cancers
FDG-PET/CT: Removed routine preop PET/CT for biliary tract cancers (NCCN alignment)

FDG-PET/CT: Added management allowance when standard imaging cannot be done or is nondiagnostic (NCCN "consider" for equivocal finding)

Lung cancer – non-small cell
FDG-PET/CT: Added management allowance when recurrence demonstrated by surveillance imaging (NCCN alignment)

Lung cancer – small cell
FDG-PET/CT: Clarification of initial staging allowance (NCCN alignment

Lymphoma – Non-Hodgkin and Leukemia
FDG-PET/CT: NCCN alignment for interim restaging (allowed for DLBCL stage I-IV with or without bulky disease)

Melanoma
Added surveillance option with MRI abdomen for liver metastases.

Prostate cancer
18F Fluciclovine PET/CT or 11C Choline PET/CT, 68GaProstate-specific membrane antigen (PSMA) PET/CT or 18F-DCFPyL (piflufolastat or Pylarify) PET/CT
Addition of diagnostic workup/initial staging indication.
Specification of androgen-receptor pathway inhibitor treatment in alignment with Carelon Medical Benefits Management Inc. Radiation Oncology Guidelines.

Sarcomas of bone/soft tissue
FDG-PET/CT: Added allowance when standard imaging nondiagnostic or contraindicated (bone/soft tissue sarcoma).

Radiation oncology

IMRT for colon cancer
New indication for adjuvant treatment of locally advanced adenocarcinoma of the cecum.

SBRT for hepatocellular carcinoma
Modify eligibility criteria to match clinical trial RTOG 1112

EBRT/IMRT for prostate cancer
Adjust for 2 Gy fractions. The total allowed dosage is the same with each fraction is a little larger (now 2 Gy) and lower number of fractions.

Musculoskeletal: interventional pain management

Epidural injection procedures and diagnostic selective nerve root blocks
Added osteoporotic fracture as a contraindication because of increased risk of fracture and confounding source of pain.

Therapeutic intraarticular facet joint injections
Added exclusions for use of endoscopic neurolysis or rhizotomy, Diagnostic medial branch blocks, therapeutic intraarticular facet joint injections, and radiofrequency neurotomy when performed at C0-C1 or at C1-C2, and Platelet-rich plasma injections

Spinal cord and dorsal root ganglion stimulators
Added indication of PDN for spinal cord stimulation with strict criteria. Added clarifications.

Sacroiliac Joint Fusion
Revised exclusion to include procedures that use a transfixing device.

Rehabilitative services

Physical therapy, occupational therapy, speech therapy

Adjunctive & alternative treatments physical therapy
Added Fluidotherapy as an exclusion.
Removed the following services from the list of Exclusions: Active Therapeutic Movement®, Interactive metronome®, MEDEK (Dynamic Method of Kinetic Stimulation)®, Whole body advanced exercise, and Whole body vibration

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

Access Carelon Medical Benefits Management ProviderPortal_SM directly at providerportal.com.
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

NYBCBS-CDCRCM-043715-23-CPN42002

Prior AuthorizationMedicare AdvantageJanuary 10, 2024

Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024

As communicated in the November 2023, provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical, and Radiation Therapy programs.

Refer to attachment to view full details

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

NYBCBS-CR-045223-23-CPN44885

ATTACHMENTS (available on web): Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024 (pdf - 0.09mb)

Prior AuthorizationCommercialJanuary 1, 2024

Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024

As communicated in the October 2023 provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management expanded cardiology, genetic testing, radiology, musculoskeletal, surgical and radiation oncology programs. The Clinical Guidelines and Medical Policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1,2024, and after.

Members included in the new program

All fully insured, self-funded (ASO), HealthLink, and National members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of April 1, 2024. A separate notice will be published for Medicare Advantage, Medicare, and MA GRS.

Members of the following products are excluded: Medicaid, Medicare supplement, Federal Employee Program® (FEP®).

Pre-service review requirements

To determine if prior authorization is needed for a member on or after April 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information.  Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials website to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management).

For procedures that are scheduled to begin on or after April 1, 2024, all providers with the following programs must contact Carelon Medical Benefits Management to obtain pre-service review for the services including but not limited to the following non-emergency modalities. Please refer to the Clinical Guidelines on the microsite resource pages for complete code lists.

Note: The procedure list has been updated since the November notification. All codes will only be reviewed for medical necessity for the requested service and not for site of care at this time.

Program	Services	Clinical Guidelines
Expanded cardiology	Treatment of varicose veins Artery stent placement w/wo angioplasty Embolization procedure Dialysis circuit procedure EPS studies Cardiac ablation Cardiac monitor device Cardiac contractility modulation Wearable cardioverter defibrillators Wireless CRT for left ventricular pacing Venous angioplasty w/wo stent placement Vein embolization treatment for pelvic congestion syndrome and varicocele PFO closure devices	CG-MED-64 CG-MED-74 CG-SURG-28 CG-SURG-55 CG-SURG-76 CG-SURG-83 CG-SURG-93 CG-SURG-106 MED.00055 RAD.00059 SURG.00032 SURG.00037 SURG.00062 SURG.00152 SURG.00153 THER-RAD.00012
Genetic testing	Topographic genotyping Chromosomal microarray analysis Gene expression profiling Gene mutation testing Gene sequencing Panel and other multi-gene test for polymorphisms Genetic test for inherited diseases Molecular marker evaluation of thyroid nodules Hybrid personalized molecular residual disease test for cancer BRCA gene test Cell-free DNA test to aid in monitoring of kidney transplant rejection Laboratory test to aid in dx of heart transplant rejection	Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing Cell-free DNA Testing (Liquid Biopsy) for the Management of Cancer Chromosomal Microarray Analysis Genetic Testing for Inherited Conditions Hereditary Cancer Testing LAB.00025 LAB.00050 Pharmacogenomic Testing Polygenic Risk Scores Somatic Tumor Testing Whole Exome Sequencing and Whole Genome Sequencing
Radiology	Radiostereometric analysis Quantitative ultrasound for tissue characterization Myocardial sympathetic innervation and imaging w/wo spect. Lumbar discography	CG-SURG-29 RAD.00064 RAD.00065 RAD.00067
Musculoskeletal	Extraosseous subtalar joint imp and arthroereisis Genicular Nerve block and ablation — CHR knee pain Percutaneous and endo spinal surgery Implanted devices for spinal stenosis Percutaneous vert disc and endplate procedures Cryoablation for podiatric conditions	SURG.00052 SURG.00071 SURG.00092 SURG.00100 SURG.00104 SURG.00142
Surgical	Wireless capsule endoscopy Bariatric surgery Paraoesophageal hernia repair Ablation proc. — treatment of Barrett’s esophagus Transendoscopic therapy for GE reflux/dysphagia/gastroparesis Lower esophageal sphincter augmentation devices	CG-SURG-83 CG-SURG-92 CG-SURG-101 MED.00090 SURG.00047 SURG.00131
Radiation oncology	Hyperthermia for cancer therapy	CG-MED-72

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortal_SM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com to register.

For more information

For resources to help your practice get started with the radiology, expanded cardiology, genetic testing, musculoskeletal, surgical, and radiation oncology programs, go to:

These websites include helpful information and tools such as order entry checklists, Clinical Guidelines, and FAQs. You can also call your local provider relationship management representative if you have any questions.

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

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MULTI-BCBS-CM-047241-23

Prior AuthorizationMedicaidDecember 19, 2023

Prior authorization requirement changes effective February 1, 2024

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

Effective February 1, 2024, prior authorization (PA) requirements will change for the following codes. The medical codes listed below will require PA by Anthem for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following codes:

Code	Description
20979	Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
A7025	High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each

To request PA, you may use one of the following methods:

Web: Once logged in to Availity at Availity.com.
Fax: 800-964-3627
Phone: 800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://providers.anthem.com/ny on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 800-450-8753 for assistance with PA requirements.

UM AROW A2023M0533

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.

NYBCBS-CD-045407-23-CPN44255

Prior AuthorizationMedicaidDecember 8, 2023

Prior authorization requirement changes effective February 1, 2024

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

Effective February 1, 2024, prior authorization (PA) requirements will change for the following code. The medical code listed below will require PA by Empire BlueCross BlueShield HealthPlus for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Code	Description
J1411	Injection, etranacogene dezaparvovec-drlb, per therapeutic dose

To request PA, you may use one of the following methods:

Web: Availity Essentials platform at Availity.com.
Fax: 800-964-3627
Phone: 800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to providers on providerpublic.empireblue.com on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 800-450-8753 for assistance with PA requirements.

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Relations associate or call Provider Services at 800-450-8753.

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross Blue Shield Association.

NYBCBS-CD-039441-23-CPN38396

DentalCommercialJanuary 1, 2024

January Dental newsletter communications

Welcome to our monthly provider newsletter: stay informed

We are thrilled to include our dental providers in our monthly provider newsletter. In these monthly publications, we will communicate important updates, informative educational articles, and more.

New articles are published on the first business day of each month, so be sure to bookmark this location and visit this page regularly for updates. Our dedicated team is committed to making important information easy for you to find, so that you can continue providing excellent care to your patients.

Empire BlueCross and Empire BlueCross BlueShield HealthPlus are transitioning to Anthem

We are very excited to share the news that on January 1, 2024, Empire BlueCross BlueShield HealthPlus (Empire) and Empire BlueCross (Empire) will become Anthem. This will take place across all lines of business. There will be no impact to your contract, reimbursement, or level of support.

Why is Empire becoming Anthem?

Empire joined the Anthem family of health plans in 2006. The decision brings together everything that the well-respected, industry-leading Anthem brand has to offer, with the strength and value of the Blue Cross and Blue Shield brand that our members have come to know and trust.

We will continue to combine the trust of the Blue Cross and Blue Shield name and the national resources and capabilities of our parent company and affiliates to improve the whole health of all our members.

For you and your patients, our priority is to make this a simple, seamless transition, so patients can continue to use the same dentist they do today:

Our provider networks are not changing.
Your patients’ plan, coverage, and ID card numbers are not changing. We will be sending out new ID cards this year, and both the new Anthem-branded cards and old Empire-branded cards will be valid.
We will still offer the same high-quality, affordable health benefits.
We will continue to offer the same programs and services to help your patients take care of their overall health and well-being.

Our existing Anthem-branded health plans in our other Blue-licensed markets are not changing and will continue to operate in their current states.

Keeping you well informed is a top priority

While our official launch isn’t until January 1, 2024, we will be communicating the news and updates to our partners, customers, and members in advance to help prepare for this transition.
For more information, please read the press release.

Consolidated Appropriations Act provider directory federal mandate – provider directories effective January 1, 2022

As required by the Consolidated Appropriations Act (CAA) and several state laws, we must ensure our provider directories are accurate. Your patients, our members, need the most up-to-date information to reach you. Please keep us informed of any changes impacting you or your office, especially those changes impacting the directory.

We will reach out to our contracted providers as required by Federal and State laws to verify contact information. As a contracted provider, you must respond to the notification by providing updated contact information.

We appreciate your due diligence in keeping us informed of any changes impacting you or your office. Working together, we ensure your patients, our members, can reach you quickly while we meet our compliance obligations.

NYBCBS-DEN-047175-23-CPN47030

DentalCommercialJanuary 1, 2024

Dental Dispatch - News and information for network providers

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

Dental Dispatch - News and information for network providers

Refer to attachment to view full details.

NYBCBS-DEN-041484-23-CPN40454

ATTACHMENTS (available on web): Dental Newsletter - Fall Winter 2023 (pdf - 0.95mb)

PharmacyCommercialDecember 28, 2023

Specialty pharmacy updates — January 2024

Specialty pharmacy updates for Anthem are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of the National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Correction: In the August 2023 edition of Provider News, we announced prior authorizations for Zynyz would be effective November 2023. In the September 2023 edition of Provider News, we announced prior authorizations for Epkinly would be effective December 2023.

Please be advised that the prior authorization effective date for Epkinly and Zynyz is January 1, 2024.

Clinical Criteria	Drug	HCPCS or CPT® code(s)
CC-0242*	Epkinly (epcoritamab-bysp)	C9155, J3490, J3590, J9999
CC-0240*	Zynyz (retifanlimab-dlwr)	J9345

* Oncology use is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

Clinical Criteria	Drug	HCPCS or CPT code(s)
CC-0068	Ngenla (somatrogon-ghla)	J3590, C9399
CC-0018	Pombiliti (cipaglucosidase alfa-atga)	J3490, J3590
CC-0020	Tyruko (natalizumab-sztn)	J3490, J3590
CC-0248*	Elrexfio (elranatamab-bcmm)	C9165, J3590, J9999, C9399
CC-0249*	Talvey (talquetamab-tgvs)	C9163, J3590, J9999, C9399
CC-0250	Veopoz (pozelimab-bbfg)	C9399, J3590
CC-0251	Ycanth (cantharidin)	C9164, J3490

* Oncology use is managed by Carelon Medical Benefits Management.

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

Step therapy updates

Effective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

The preferred product in the Tyruko step therapy is generic dimethyl fumarate.

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

Clinical Criteria	Status	Drug	HCPCS or CPT code(s)
CC-0020	Non-preferred	Tyruko (natalizumab-sztn)	J3490, J3590

Courtesy notice

Effective on or after October 30, 2023, step therapy criteria for vascular endothelial growth factor (VEGF) inhibitors found in Clinical Criteria document CC-0072 expands the preferred product list to include Eylea HD. Please refer to Clinical Criteria document for details.

Quantity limit updates

Effective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

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

Clinical Criteria	Drug	HCPCS or CPT code(s)
CC-0018	Pombiliti (cipaglucosidase alfa-atga)	J3490, J3590
CC-0020	Tyruko (natalizumab-sztn)	J3490, J3590
CC-0250	Veopoz (pozelimab-bbfg)	C9399, J3590
CC-0251	Ycanth (cantharidin)	C9164, J3490

Site of care updates

Effective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.

Access our Clinical Criteria to view the complete information for these site of care updates.

Clinical Criteria	Drug	HCPCS or CPT code(s)
CC-0189	Amondys 45 (casimersen)	J1426
CC-0241	Elfabrio (pegunigalsidase alfa-iwxj)	J2508
CC-0193	Evkeeza (evinacumab)	J1305
CC-0044	Exondys 51 (eteplirsen)	J1428
CC-0154	Givlaari (givosiran)	J0223
CC-0231	Lamzede (velmanase alfa-tycv)	J0217
CC-0209	Leqvio (inclisiran)	J1306
CC-0013	Mepsevii (vestronidase alfa)	J3397
CC-0185	Oxlumo (lumasiran)	J0224
CC-0073	Prolastin (alpha 1 proteinase inhibitor)	J0256
CC-0049	Radicava (edaravone)	J1301
CC-0246	Rystiggo (rozanolixizumab-noli)	J9333
CC-0225	Tzield (teplizumab-mzwv)	J9381
CC-0170	Uplizna (inebilizumab-cdon)	J1823
CC-0172	Viltepso (viltolarsen)	J1427
CC-0160	Vyepti (eptinezumab-jjmr)	J3032
CC-0152	Vyondys 53 (golodirsen)	J1429
CC-0207	Vyvgart Hytrulo (efgartigimod alfa 2 mg and hyaluronidase-qvfc)	J9334

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

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Quality ManagementCommercialMedicare AdvantageMedicaidJanuary 1, 2024

HEDIS 2023 Electronic Clinical Data Systems (ECDS)

HEDIS^® measure data is collected by one or more methods:

Administrative method — claims and supplemental data
Hybrid method — administrative and medical record data
Survey method — Health Outcomes Survey (HOS) & Consumer Assessment of Healthcare Providers & Systems (CAHPS^®)
Electronic Clinical Data Systems (ECDS) — HEDIS reporting standard that leverages electronic data from multiple sources. See below.

The HEDIS Electronic Clinical Data Systems (ECDS) Reporting Standard was introduced in HEDIS 2016 (measurement year 2015) by the National Committee of Quality Assurance (NCQA) and encourages health information exchange, which is the secure sharing of patient medical information electronically. ECDS data collection is part of NCQA’s nationwide plan to capture information regarding aspects of care quality with less reliance on clinical medical record review.

There are four types of ECDS:

Electronic Health Record (EHR)/Personal Health Record (PHR): Real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs eligible for this category of ECDS reporting include the NCQA eMeasure certification program or any system that meets the 2015 Edition Base Electronic Health Record (EHR) definition.
Health Information Exchange (HIE)/Clinical Registry: HIEs and clinical registries eligible for this reporting category include state HIEs, immunization information systems (IIS), public health agency systems, regional HIEs (RHIO), Patient-Centered Data Homes™, or other registries developed for research or to support quality improvement and patient safety initiatives. Doctors, nurses, pharmacists, other health care providers, and patients can use HIEs to access and share vital medical information, with the goal of creating a complete patient record. Clinical registries can be sponsored by a government agency, nonprofit organization, health care facility or private company, and decisions regarding use of the data in the registry are the responsibility of the registry’s governing committee.
Case Management System: A shared database of member information collected through a collaborative process of member assessment, care planning, care coordination or monitoring of a member’s functional status and care experience. Case management systems eligible for this category of ECDS reporting include any system developed to support the organization’s case/disease management activities, including activities performed by delegates.
Administrative: Includes data from administrative claim processing systems for all services incurred (in other words, paid, suspended, pending, and denied) during the period defined by each measure’s participation as well as member management files, member eligibility and enrollment files, electronic member rosters, internal audit files, and member call service databases.

Having more time to focus on patient care rather than responding to medical record requests is possible by participating in Electronic Clinical Data Systems (ECDS). We are focused on reducing administrative burdens, so you can do what you do best — care for our members. Let us help by granting EMR Direct Remote access to our EMR team.

Need more information or ready to sign up?

Please email us today at: Centralized_EMR_Team@anthem.com.

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

NYBCBS-CDCRCM-041628-23-CPN41091

Quality ManagementMedicare AdvantageJanuary 1, 2024

Boost annual planned visit rates

We’re committed to ensuring every eligible member receives an Annual Planned Visit (APV) this year and appreciate your help to make this happen.

Tips to help your practice boost APV rates early in the year:

Members do not need to wait a full calendar year between wellness visits. Coverage resets on January 1, and we encourage all eligible members to schedule wellness visits with their care provider.
Outreach to members within their first year of Medicare to schedule their Welcome to Medicare Exam (or Initial preventive physical exam, IPPE) and explain its importance.
Know who your hard-to-engage members are and start contacting them earlier in the year.
The Provider News Quality Management page is a great resource to learn more about optimizing your quality scores and staying up to date on our latest communications.
While everyone is eligible for an annual wellness visit, some of the topics discussed during the visit may require additional follow-up to close a care gap. Be aware of scheduling lead times with other facilities for certain visit types, like mammograms, DEXA scans, and colonoscopies. Try to prioritize these patients who need these services for wellness visits.
The AWV is a hands-off appointment that can be conducted via telehealth. This may be a great option for patients with mobility or access issues or compromised immune systems. See our guide for how to facilitate these exams via telehealth here.

APV coding guidelines:

*Verify member’s benefits and eligibility prior to scheduling

NYBCBS-CR-040779-23-CPN40559

ATTACHMENTS (available on web): Boost annual planned visit rates (pdf - 0.33mb)

Quality ManagementCommercialNovember 20, 2023

Annual preventive care visits

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

With the New Year, people often make resolutions or set goals for themselves. Let this be the year that you see all your patients for their annual preventive care visit.

As you know, annual visits are mutually beneficial to both you and your patients. These visits help establish a strong provider-patient relationship, which is essential in achieving the best healthcare outcomes. Establishing baseline measurements, knowing family history, and understanding unique risk factors and concerns can help you provide appropriate and culturally sensitive guidance on reducing risk for disease. Patients who report positive interactions with their healthcare providers demonstrate greater self-management and quality of life, as well as a reduction in emergency room visits and inpatient admissions.

Start the new year on the right foot:

If you are seeing a patient for the first time, ask them to have their previous provider send their medical records.
Begin reaching out to harder to engage patients early in the year.
Reach out to patients at least [two months] prior to their birthday to schedule an appointment.
Remind patients of their upcoming appointment via phone, text, and/or email as it approaches to avoid no shows.
Remember to verify your patient’s benefits and eligibility prior to scheduling appointments.
Screen for social needs that may be a barrier for care.
If you need to refer a patient for a test or to a specialist, manage their expectations and follow-up with both the patient and provider.

Make sure to get the credit you deserve by reporting all services provided and use all appropriate billing codes:

The annual visit service is coded based on the patient’s age.
Use CPT^® Category II codes with your claims encounters to maximize HEDIS^® data collection and reduce the burden of HEDISmedical record review. Go to the American Medical Association website at ama-assn.org for a complete list of CPT codes.

If you are using an electronic medical record system, consider electronic data sharing with the health plan to capture all coded elements to facilitate HEDISdata collection and more accurate gap in care reports.

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

NYBCBS-CM-045212-23-CPN44820

January 2024 Provider Newsletter

Contents

To view this publication online:

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Quantum Health is the point of contact for member and care provider inquiries.

Anthem will remain the point of contact for care providers for the following:

Sample member ID card

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Now accepting Medicaid and Medicare member claims

Learn more!

Not a Digital RFAI care provider?

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Making the Claims Process Work for You — a short on-demand video and step-by-step guide

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What happens next?

What is the benefit to you and your patients?

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How to find Provider Pathways

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Radiology

Imaging of the heart

Imaging of the brain

Imaging of the chest

Imaging of the head and neck

Oncologic imaging

Cancer screening

Radiation oncology

Musculoskeletal: interventional pain management

Rehabilitative services

Physical therapy, occupational therapy, speech therapy

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Members included in the new program

Pre-service review requirements

For more information

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Welcome to our monthly provider newsletter: stay informed

Empire BlueCross and Empire BlueCross BlueShield HealthPlus are transitioning to Anthem

Why is Empire becoming Anthem?

Keeping you well informed is a top priority

Consolidated Appropriations Act provider directory federal mandate – provider directories effective January 1, 2022

To view this article online:

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Prior authorization updates

Step therapy updates

Courtesy notice

Quantity limit updates

Site of care updates

To view this article online:

Need more information or ready to sign up?

To view this article online:

Tips to help your practice boost APV rates early in the year:

APV coding guidelines:

To view this article online:

To view this article online: