On June 15, 2018, the direct login link to the Empire BlueCross BlueShield (“Empire”) Facility and Professional secure web portals will be removed from the Empire provider public web page.  Your only access to the secure portal will be through the Availity Portal.

This single sign on process simplifies your access eliminating the need to log into two separate portals.

What you need to access the Empire Facility and Professional Portals from the Availity Portal:

1. Empire Facility Health Plan User ID (assigned by your Empire Super User).
2. Unique Availity user ID & password (assigned by your Availity administrator).
3. Registered as a user for Empire Services Registration on Availity.

Not a registered User of Empire Services Registration?

Your Availity administrator can set you up by taking the following steps on Availity:

• Select:  Payer Spaces | Resources | Services Registration | Non-Registered Users.
• Next, type the Empire Health Plan ID in the appropriate field (Facility and/or Professional) then scroll down to the bottom of the page and select Register.

Don’t know who your Availity administrator is?

From Availity’s home page select: My Account Dashboard | My Administrators

 Accessing Empire Facility and Professional Secure Portals from Availity Portal:

Once you are registered for Empire Services Registration select Payer Spaces | Resources |Empire Facility or Empire Professional link.

Empire has recently moved into a strategic partnership with Availity to serve as our designated EDI Gateway and E-solutions Service Desk.

• Availity and Empire are working together to develop new ways to simplify how you manage claims and other administrative tasks online.
• Beginning June 1^st 2018 you will be able to manage all changes and new setup requests for the electronic remittance advice (835) through the Availity Portal. 
• To register or manage account changes for electronic funds transfers (EFT) only, please continue to use the EnrollHub at https://solutions.caqh.org
• If you directly submit your electronic transactions to Empire and have your own practice management software, Availity provides trading partner services and access to Portal tools through an easy setup experience. 
• If you use a clearinghouse, they will work with Availity on your behalf.

Next Steps If you are a Direct Submitter:

Key Factors:

• You will be able to manage changes or new registrations for the electronic remittance advice (835) through your Availity Portal account beginning June 1^st 2018. We encourage you to register with Availity to initiate the change to the Availity EDI Gateway.
• Empire and Availity are committed to transparency with this change, and will emphasize the continuity of quality service to our trading partners.

We look forward to delivering a smooth transition to Availity for our EDI services. If you have any questions or concerns please contact the E-Solutions service desk at 1-800-470-9630 or Availity at 1-800-AVAILITY (282-4548)

Beginning August 20, 2018 Interactive Care Reviewer (ICR) will be your exclusive online tool for initiating and checking the status for many of your inpatient medical authorizations; and inpatient and outpatient behavioral health authorizations for Empire local market membership.*

The ICR offers a streamlined process to request these inpatient and outpatient procedures through the Availity Portal.

How do I gain access to the ICR?

You can access our ICR tool via the Availity Portal. If your organization has not yet registered for Availity, go to www.availity.com and select Register in the upper right-hand corner of the page.

If your organization already has access to Availity, your Availity administrator can grant you access to “authorization and referral request” for submission capability and “authorization and referral inquiry” for inquiry capability.

You can then find our tool under Patient Registration | Authorizations & Referrals. Then select the Authorizations or Authorization/Referral Inquiry option as appropriate.

Is ICR training available for providers?

You can attend one of the ICR monthly webinars. Register for the next webinar here: [https://anthemincub.webex.com/anthemincub/onstage/g.php?PRID=aa5396352099172976c26a64eacbad6f].

Who can providers contact with questions?

For questions regarding our ICR, please contact your local Provider Relations representative. For questions on accessing our tool via Availity, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548). Availity Client Services is available Monday-Friday, 8 a.m.-7 p.m. Eastern time (excluding holidays) to answer your registration questions.

What benefits/efficiencies does the ICR provide?

• You are automatically routed to our ICR. Once the ICR is available, when you go to Authorizations in the Availity Web Portal, you are automatically routed to the ICR in order to begin your prior authorization request.
• You can determine if prior authorization is needed. For most requests, when you enter patient, service and provider details, you will receive a message indicating whether or not review is required.
• You will have inquiry capability. Ordering and servicing physicians and facilities can locate information on preauthorization requests for those they are affiliated with; this includes requests previously submitted via phone, fax, ICR or another online tool (for example, AIM Specialty Health®).
• The ICR is easy to use. You can submit outpatient and inpatient requests for services online using the same, easy-to-use functionality.
• The ICR reduces the need to fax. The ICR allows text detail as well as images to be submitted along with the request. Therefore, you can submit requests online and reduce the need to fax medical records.
• There is no additional cost to you. The ICR is a no-cost solution that’s easy to learn and even easier to use.
• You can access the ICR tool almost anywhere. You can submit your requests from any computer with internet access. (Note: We recommend you use Internet Explorer 11, Chrome, Firefox or Safari for optimal viewing.)
• You receive a comprehensive view of all your preauthorization requests. You have a complete view of all the utilization management requests you submitted online, including the status of your requests and specific views that provide case updates and a copy of associated letters.

*Coming later in 2018 – ICR will be available for Medical outpatient authorizations, National Account membership, Medicaid and Medicare Advantage membership. Look for announcements informing you of these additions in upcoming communications.

Empire streamlines member identification cards

Beginning July 1, 2018, Empire will introduce a streamlined member identification (ID) card to help reduce confusion about member cost share. The updated member ID card will maintain the current style, but specific cost share information (such as copays or coinsurance) will be removed from the card.

Providers access Availity and the Electronic Data Interchange (EDI) to verify member benefits and obtain the most up-to-date cost share information for a member’s plan. If a member presents an older ID card with outdated benefits at the provider office, it can create confusion about member cost share.

As the streamlined ID card is adopted, it will help reduce misunderstandings around cost share. Additionally, members will be encouraged to learn more about their benefits through Empire’s digital and online tools, and can retain their card for as long as they remain in the same product plan, regardless of changes to cost share information.

As a reminder, members can now view, download, email, and fax an electronic version of their member ID card using the Empire Anywhere mobile app. Electronic ID cards will also be updated as described above.

Please note, this update does not apply to National Accounts, Federal Employee Program ® (FEP ®), Medicaid or Medicare plans.

For questions, please contact the provider service number on the back of the member ID card.

Empire reviews and updates our online Provider Manuals annually.  The updated manual is now available online at empireblue.com/provider > Click “Find Resources in New York” > Provider Home >  Communications > Empire’s Provider Manual. The following changes are effective July 1, 2018:

New Content for 2018

• Pharmacy Home
• Availity Portal
• AIM Specialty Health
• Claims Filing Tips
• Online Provider Directories and Demographic Data Integrity

Updated for 2018:

• Misrouted PHI
• Risk Adjustments
• Overview of CAHPS
• EDI
• Overpayment-Cost Containment
• Medicare Crossover
• Implants
• Medical Care Provided to or by a Family Member
• Test or Procedures Prior to Admission(s) or Outpatient Services
• Preventable Adverse Events (PAE)
• Credentialing
• Utilization Management
• Member Rights and Responsibilities
• Quality Improvement
• Cultural Diversity
• Continuity and Coordination of Care 
• Continuity of Care/Transition of Care Program
• Quality of Care Investigations
• Clinical Practice Guidelines
• Preventive Health Guidelines
• Performance Data
• Medical Policy (excluding CA)
• Centers of Medical Excellence
• Member Health & Wellness
• Blue Card Overview
• FEHBP
• HIX
• Audit  -excluding CA
• Fraud Waste and Abuse Detection

Empire has engaged with InstaMed®, a healthcare payments network, to offer Healthcare Bill Payments. InstaMed is a Payment Card Industry (PCI) Level One Service Provider and certified at the highest levels for both healthcare and payment processing.

Providers registered with InstaMed will conveniently receive patient payments by direct deposit into their bank account without ever mailing a patient bill or making a phone call. Plus, patients enjoy a simple, convenient payment option.

Registration for Healthcare Bill Payments is simple – you can get started today. Here’s what you’ll need:

• Email address
• Tax ID number for your organization
• Bank account information for direct deposit

If you are not registered, these payments are mailed to you as prepaid Mastercard® payments.

For more information about Healthcare Bill Payments:

• Register to attend InstaMed’s upcoming informational webinar on June 14, 2018 at 1:00 pm ET.
• Read more about Healthcare Bill Payments.
• See InstaMed’s Frequently Asked Questions. 
• Email questions about Healthcare Bill Payments to connect@instamed.com.

This feature does not apply to Empire Medicare and Medicaid plans, but may be implemented in the future.

Empire continually evaluates coding and billing patterns, and recently identified trends related to the use of code E1399 — DME, miscellaneous. When an appropriate code exists for DME equipment or supply, the more specific code should be used.

Inappropriate use of code E1399 often includes, but is not limited to the following:

• Gait trainers (E8001/E8002)
• Shower chairs (E0240)
• Standing frames (E0641)
• Hospital beds (E0250-E0373)
• Stand assist lifts (E0635)

To ensure proper use of E1399, Empire conduct post-payment reviews of code E1399.  If a more appropriate code should have been used, Empire may recoup overpayments accordingly.

Empire continues to require prior authorization for the use of miscellaneous code E1399. If a prior authorization is approved but the claim is submitted with the incorrect code E1399, then the claim may be denied and a corrected claim will need to be resubmitted with the appropriate HCPCS code.

Effective with dates of service on and after October 31, 2018, Empire will begin using MCG Care Guidelines 22nd edition Behavioral Health guidelines for the review of behavioral health services.  This represents a change from the behavioral health medical policies and clinical guidelines currently used. 

Please note that the following behavioral health (BEH) medical policies and clinical guidelines will be retained at this time:

• BEH.00002 Transcranial Magnetic Stimulation
• BEH.00004 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-BEH-01 Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
• CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder
• CG-BEH-14 Intensive In-Home Behavioral Health Services

Empire may continue to use additional medical policies and clinical guidelines to supplement MCG Care Guidelines.

View Empire’s medical policies and clinical guidelines and view Customizations to MCG Care Guidelines 22nd edition.

This change impacts Empire’s Commercial health plans.

Providers should continue to call the phone number indicated on the back of the member ID card to request prior authorization review or for additional questions regarding behavioral health.

Please note that we no longer manage traditional behavioral health outpatient therapy for all fully insured products, including our health insurance exchange products. Many of our self-funded groups have also removed review of the traditional outpatient therapy visits; however, some groups continue to require a review after a certain number of pass-through visits. Please be certain to verify benefits for new patients to help ensure you are aware of any requirements. Partial hospitalization, intensive outpatient, applied behavior analysis, trans-cranial magnetic stimulation (TMS) services continue to require prior authorization from the first visit.

These updates list the new and/or revised Empire medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service.  Previously processed claims will not be reprocessed as a result of the changes.  If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire.  Please include this update with your Provider Manual for future reference. 

Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.  Empire’s medical policies and clinical guidelines can be found at empireblue.com.

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

Empire recently discovered that some claims with services under the following programs are processing without the required prior authorization through AIM Specialty Health® (AIM), a separate company:

• Sleep Management
• Radiology Oncology
• Radiology Benefit Management (RBM)
• Cardiology

Effective July 1, 2018, our claims systems will be updated to correct this issue.

Claims for Sleep Management, Radiology Oncology, Radiology Benefit Management (RBM), and Cardiology services continue to require prior authorization through AIM. For a list of the codes that require prior authorization, visit the AIM ProviderPortal℠.

As a reminder, please submit prior authorization requests to AIM in one of the following ways:

• Access AIM ProviderPortal℠ 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 AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

Beginning with dates of service on and after July 1, 2018, the following updates will apply to AIM Musculoskeletal Program Clinical Appropriateness Guidelines:

Spine Surgery guideline: 

• Cervical decompression with or without fusion:

o    Added osteotomy and corpectomy definitions

o    Clarified implant/instrumentation failure

• Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis):

o    Added osteotomy and corpectomy definitions

• Spinal stenosis:

o    Removed bilateral or wide decompression

Interventional Pain Management guideline: 

• Epidural injection procedures and diagnostic selective nerve root blocks:

o    Added prior authorization exemption for CPT codes 62320 and 62322 when used for post-procedural pain with certain ICD-10-CM diagnoses

• Repeat therapeutic epidural steroid injections, clarified initial injection as therapeutic:

o    Clarified injection sessions for procedural requirements

• Paravertebral facet injection/nerve block/neurolysis:

o    Increased procedural limitation for diagnostic medial branch blocks

o    Increased procedural limitation for therapeutic intraarticular facet joint injections and clarified requirement for conservative treatment between injections

• Sacroiliac joint injections:

o    Added HCPCS code G0260

Ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways:

• Access AIM ProviderPortalSM 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 AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

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

In the October 2017 edition of the Network Update, Empire announced a new coverage guideline, Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing (CG-MED-53) to be effective January 1, 2018. Please be advised that CG-MED-53 was not implemented. 

In the April 2018 edition of the Network Update, Empire announced an expansion of hospice benefits for local Empire fully insured plans to begin on June 1, 2018. The newly expanded benefits allow for disease modifying treatments to continue alongside hospice services, as well as member access to hospice services with prognoses of up to 12 months.

Providers should verify whether members have the expanded hospice benefit under their Empire policy.

For some health plans, updated benefit information will return via an electronic eligibility and benefit inquiry on the Availity Portal or using your Electronic Data Interchange (EDI) interface as early as June 1, 2018. We anticipate that all impacted plans will return the updated language by August 1, 2018. Once updated, hospice inquiries (Service Type 45) will confirm access to the expanded hospice benefit by returning: “LIFE EXPECTANCY UP TO 12 MONTHS WITH DISEASE MODIFYING TREATMENT ALLOWED.”

It may be necessary for providers to contact the Provider Service number on the back of the member ID card to confirm if a member’s plan includes the expanded hospice benefits from June 1, 2018 - August 1, 2018, before all systems are updated to report the more detailed benefit language. 

As a reminder, the following plans include the expanded hospice benefits beginning June 1, 2018: Commercial fully-insured group and individual plans, excluding NY standard plans. The following plans do not include expanded hospice benefits: self-insured plans, Medicare, Medicaid, and FEP and fully-insured NY standard plans.

Beginning June 1, 2018, Empire will offer an Individualized Care Program to our fully insured commercial members to provide palliative care support for members with advanced illness in the last 12 months of life.  

This program does not replace the care of PCPs and specialists, but provides an extra layer of support with an interdisciplinary team that includes palliative care physicians, palliative care nurse practitioners, registered nurses, social workers, chaplains and patient care coordinators.

Specific palliative care services include:

• Comprehensive assessments including symptoms, spiritual and psychosocial needs
• Expert symptom management
• Supporting patients in defining their goals, values and preferences and in advance care planning
• Encouraging patients to execute advance directives
• 24/7 access to urgent clinical support from an palliative care team member
• Securing needed resources
• Education on palliative services and hospice care services

An initial telephonic outreach to identified members will be made by a palliative care professional to introduce Empire’s Individualized Care Program and to determine the appropriate level of palliative services in one of the following three models:

1. Telehealth services and support at routine intervals to patients by palliative trained providers
2. Home based visits by a palliative care nurse practitioner, supported by an interdisciplinary team of palliative providers for patients with a high symptom burden, increased risk of hospitalization, or other complex issues.  The home based visits will be offered through an Empire partnership with Aspire Health (available in certain geographic areas)
3. Clinic based services offered through an Empire partnership with Aspire Health.  Aspire’s palliative care team will be embedded within the outpatient clinic/practice of the member’s medical oncologist to provide services to targeted patients (available in certain geographic areas)

Aspire Health already provides services for members with advanced illness enrolled in our Medicare and Medicaid health plans and has demonstrated improvement in quality and cost of care savings.

If you are an Empire contracted network provider, an Aspire Health palliative physician may reach out to your practice to introduce themselves in order to establish a physician to physician relationship. They may also discuss developing an individualized mechanism by which to share information regarding patients that have been identified for palliative care services. Aspire will provide clinical updates to your practice on a regular basis to facilitate the best possible co-management of your patient.

If you have questions regarding Empire’s Individualized Care Program, please email IndividualizedCareProgram-PalliativeCare@anthem.com.

Please note, this notice is only applicable to Medicare Advantage members: Cologuard, that at-home colorectal cancer screening, is covered at 100 percent for Empire Medicare Advantage individual and group-sponsored members. Members will not incur an out-of-pocket cost for the screening and no prior authorization is required.

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The Medicare peer-to-peer process facilitates a conversation between a provider and an Empire medical director. The peer-to-process should be used to explain or clarify something that a clinical record cannot convey. To learn how to initiate a peer-to-peer conversation, please see Important Medicare Advantage Updates at empireblue/medicareprovider.

Effective July 1, 2018, Empire will be a Medicare Advantage (MA) plan option for Motion Picture Industry Health and Pension Plans (MPI).  Empire will provide medical benefits for MPI retirees through a Local Preferred Provider Organization (LPPO) product.  The MA plan offers the same hospital and medical benefits that Medicare covers.  In addition, MPI retirees will pay the same cost share for both in-network and out-of-network services.  The MA plan also covers additional benefits that Medicare does not such as hearing, acupuncture, LiveHealth Online and SilverSneakers.

MPI retirees will have a customized identification card that includes the MPI logo.  The prefix on their cards will be MBL. Providers will follow their normal claim filing procedures for MPI member claims.   

Effective July 1, 2018, Empire will be a Medicare Advantage (MA) plan option for Connecticut Teachers’ Retirement Board (TRB).  Empire will provide medical benefits for TRB retirees through a Local Preferred Provider Organization (LPPO) product.  The MA plan offers the same hospital and medical benefits that Medicare covers.  The MA plan also covers additional benefits that Medicare does not such as LiveHealth Online and SilverSneakers. 

TRB retirees will have a customized identification card that includes TRB’s logo.  The prefix on their cards will be ZDX. Providers will follow their normal claim filing procedures for MPI member claims.   

We want to thank our PCPs and hospitals for their coordination of home health care for our members. We want to alert you to important changes to our Home Health provider network for most of our Medicare Advantage members. Empire will delegate its provider network for Home Health Care Services for most of our Medicare Advantage members to myNEXUS Aug. 1, 2018.  Additional information will be available at Important Medicare Advantage Updates at empireblue/medicareprovider.

Medication non-adherence increases mortality and costs the healthcare system billions of dollars per year. Empire is collaborating with physicians engaged in our Enhanced Personal Health Care (EPHC) programs to promote adherence by increasing 90-day supply prescriptions. Patients who receive 90-day supplies are more likely to be adherent, and Empire’s Medicare Advantage plans allow 90-day supplies to be filled for chronic medications at any retail pharmacy. Beginning in July, EPHC providers program will receive a monthly report that identifies Medicare members eligible for a 90-day supply.  Please evaluate that member list and discuss the benefits of a 90-day supply with your patients.

Please continue to check Important Medicare Advantage Updates at empireblue/medicareprovider, including:

• Improve Medicare Advantage members’ medication adherence with 90-day prescriptions 
• Prior authorization requirements for cardiovascular services  
• Medicare Advantage reimbursement policy provider bulletin  
• Medicare risk adjustment and documentation training  
• Dual Eligible Special Needs Plans – provider training required
• Prior authorization requirement for Electrical Stimulation Device
• Prior authorization requirements for part B drugs: Zevalin and Eptacog 
• Prior authorization requirements for Part B drug: Trelstar 

In accordance with CMS guidelines, Empire BlueCross BlueShield HealthPlus (Empire) conducts post-payment reviews of professional claims for Medicaid Managed Care members billed with modifiers for distinct procedural services (modifiers 59, XE, XP, XS and XU). As part of these reviews, we may contact you with outlying billing practices to request additional documentation related to the services. If billing discrepancies are identified, we will provide you with a written report of our findings as well as your appeal rights and may initiate recoupment as appropriate. Findings may assist your office with quality improvement efforts.

For questions regarding post-payment reviews of distinct procedural services modifiers, contact Provider Services at 1-800-450-8753.

Reminder: Miscellaneous durable medical equipment (DME) procedure codes (such as E1399) cannot be used as an alternative to specific identified codes. Empire BlueCross BlueShield HealthPlus (Empire) will conduct postpayment reviews to ensure the right codes for the right services are used. This applies to all claims for Medicaid Managed Care members.

In an effort to improve the provider experience, we continually evaluate coding and billing patterns. Recently, we identified trends related to the use of E1399 — DME, miscellaneous. This code is only intended for use when a more appropriate code is not available. When an appropriate code does exist, that code must be used regardless of your contracted rate. It is not appropriate to use E1399 for payment increases.

We continue to require prior authorization for the use of miscellaneous code E1399. To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

As it is not our policy to inform providers of proper billing processes within prior authorization responses, authorization responses do not include code-specific details. If your service was approved but your claim was denied payment when billed using E1399, the incorrect code was used. You will need to update the authorization and the claim with the appropriate HIPAA-compliant HCPCS code.

Empire will conduct postpayment reviews of code E1399 to ensure proper use. If it is determined a more appropriate code should have been used, we will notify you in writing and advise you of your appeal rights.

You can find additional information related to miscellaneous codes in the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy at www.empireblue.com/nymedicaiddoc > Precertification & Claims > Medicaid Reimbursement Policies.

Effective July 1, 2018, prior authorization (PA) is required for Mylotarg (gemtuzumab ozogamicin) to be covered by Empire BlueCross BlueShield HealthPlus through the medical benefit. Federal and state law as well as state contract language including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Mylotarg (gemtuzumab ozogamicin) — injection, gemtuzumab ozogamicin, 0.1 mg (J9203)

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

• Web: Interactive Care Reviewer tool via https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool at https://www.availity.com. Providers who are unable to access Availity may call Provider Services at 1-800-450-8753 for PA requirements.

The electrical stimulation device will require prior authorization (PA) effective August 1, 2018.

Please use the Precertification Lookup Tool for authorization requirements at http://www.empireblue.com/nymedicaiddoc > Prior Authorization & Claims > Prior Authorization Lookup Tool.

Noncompliance with the new requirements may result in denied claims. The following code will require PA:

·         E0766 — Electrical stimulation device used for cancer treatment, includes all accessories, any type

Please request PA via one of the following methods:

• Availity Portal: https://www.availity.com
• Fax: 1-800-964-3627
• Phone:   1-800-450-8753

Federal law, state law and state contract language (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage.

If you have questions about this communication or need assistance with any other item, call Provider Services at
1-800-450-8753.

Chimeric antigen receptor T-cell (CAR T) therapy, including immunotherapy and all inpatient stays, will continue to require a prior authorization (PA) regardless of the place of service in which it is given.

CAR T codes require PA, and all requests must be reviewed by Empire BlueCross BlueShield HealthPlus for PA regardless of place of service or if billed with an unlisted code.

Please refer to the Precertification Lookup Tool for detailed PA requirements by visiting http://www.empireblue.com/nymedicaiddoc and choosing Precertification Lookup Tool from the Precertification & Claims menu.

CAR T therapy is currently represented by the following codes:

• Q2040 — Tisagenlecleucel (brand name: Kymriah™), up to 250 million CAR-positive viable T-cells, including leukapheresis and dose-preparation procedures, per infusion.
• Q2041 — Axicabtagene Ciloleucel, up to 200 million autologous anti-CD19 CAR T-cells, including leukapheresis and dose-preparation procedures, per infusion (new code effective April 1, 2018).

CAR T therapy in any form will continue to require PA. Please use one of the following methods to submit a request:

• Web: www.availity.com
• Fax: 1-800-964-3627
• Phone:1-800-450-8753

Noncompliance with these requirements may result in denied claims. Federal and state law, as well as state contract language including definitions, and specific contract provisions and exclusions, take precedence over these PA rules and must be considered first when determining coverage.

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-450-8753.

Effective July 1, 2018, lower extremity vascular intervention codes will require prior authorization (PA) by Empire BlueCross BlueShield HealthPlus.

Please refer to the Precertification Lookup Tool for detailed PA requirements by visiting http://www.empireblue.com/nymedicaiddoc and choosing Precertification Lookup Tool from the Precertification & Claims menu.

PA requirements will be added to the following codes:

• 37220 — Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty
• 37221 — Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• 37224 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty
• 37225 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed
• 37226 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• 37227 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
• 37228 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty
• 37229 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed
• 37230 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• 37231 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

Please use one of the following methods to request PA:

CAR T therapy in any form will continue to require PA. Please use one of the following methods to submit a request:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone:1-800-450-8753

Noncompliance with these requirements may result in denied claims. Federal and state law, as well as state contract language including definitions, and specific contract provisions and exclusions, take precedence over these PA rules and must be considered first when determining coverage.

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-450-8753.

Effective August 1, 2018, Empire BlueCross BlueShield HealthPlus prior authorization (PA) requirements will change for the injectable drug Darzalex (daratumumab) 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. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to:

• J9145 — Injection, Darzalex (daratumumab), 10 mg

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

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool (https://www.availity.com). Contracted and noncontracted providers who are unable to access Availity may call us at 1-800-450-8753 for PA requirements.

All programs require prior authorization (PA) for all covered specialty medications, where allowable by state. The scope of this notice will include both professional and facility requests for Medicaid business.

Specialty medications that are reported with not otherwise classified (NOC) designation codes and

C codes may also require PA before services are provided.

Regardless of whether PA is required, all services must be medically necessary to be covered. Even if PA is not required, to avoid a claim denial based on medical necessity, Empire BlueCross BlueShield HealthPlus (Empire) encourages providers to review our medical necessity criteria prior to rendering nonemergent services. Medical necessity criteria can be accessed by visiting http://www.empireblue.com/nymedicaiddoc to view the most current Medical Policies and Clinical Utilization Management Guidelines.

If no specific policy is available, the medical necessity review of a drug may be conducted using Medical Policy ADMIN.00006: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management Guideline and/or Clinical Utilization Management Guideline CG-DRUG-01: Off-Label Drug and Approved Orphan Drug Use.

Clinical review of specialty medications is in addition to services currently requiring PA. Providers are responsible for verifying eligibility and benefits for Empire members before providing services. We recommend providers visit http://www.empireblue.com/nymedicaiddoc to review the list of services and service categories currently requiring PA, with a reminder that the list of services requiring PA will be updated as needed. For clarification regarding whether a specific code or service requires PA, call the number listed below. Except in an emergency, failure to obtain PA may result in denial of reimbursement.

Again, please be reminded that the list of services requiring PA will be updated as needed.

Requesting PA

To request PA, report a medical admission or for questions regarding PA, providers may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

Providers are strongly encouraged to revisit the Government Business Division Reimbursement Policy Unlisted or Miscellaneous Codes policy, which states NOC codes must be submitted with the correct national drug code (NDC) for proper claim payment. If the required NDC data elements are missing or invalid for the procedure code on a claim line, the claim will be denied.

Medical Policies update On February 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies which are applicable to Empire BlueCross BlueShield HealthPlus (Empire). These medical policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the listing below. The medical policies were made publicly available on the provider website on the publish date listed below. To search for specific policies, visit http://www.empireblue.com/medicalpolicies/search.html. Existing precertification requirements have not changed.

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

Clinical Utilization Management Guidelines update

On February 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Clinical Utilization Management (UM) Guidelines which are applicable to Empire. These clinical guidelines were developed or revised to support clinical coding edits. Several Guidelines were revised to provide clarification only and are not included in the listing below. The Clinical UM Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division on March 30, 2018. To see the full utilization management guidelines on the website, visit http://www.empireblue.com/medicalpolicies/search.html.

On March 30, 2018, the clinical guidelines were made publicly available on the Empire Medical Policies and Clinical UM Guidelines subsidiary website. To search for specific guidelines policies, visit http://www.empireblue.com/medicalpolicies/search.html. Existing precertification requirements have not changed.

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

Update to clinical guideline, CG-MED-39, Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry (CG-MED 39), was published March 30, 2018.

Effective March 30, 2018, this clinical guideline will apply to Medicaid lines of business.

The clinical indication section specific to female screening of osteoporosis was revised to reflect that an initial (baseline) central (hip or spine) bone density measurement is considered medically necessary when conducted in postmenopausal individuals 65 years of age or older.

The guideline also identifies other clinical indications when initial and repeat central bone mineral density measurements are medically necessary.

The Uniform Clinical Network Provider Training is a unified state-of-the-art, web-based training for Medicaid managed care network providers in clinical core competencies and evidence-based practices for mental health and substance use disorder services. New York State (NYS) requires that Medicaid managed care organizations (MMCOs) offer training to network providers in behavioral health core clinical competencies and evidence-based practices. NYS Office of Mental Health (OMH) and Office of Alcoholism and Substance Abuse Services (OASAS) have additionally mandated that the mainstream and Health and Recovery Plan MMCOs must provide a uniform behavioral health network provider training program to standardize the trainings and minimize duplicative requirements from multiple MMCOs. The NYS Health Plan Association is collaborating with the Center for Practice Innovations (CPI) at Columbia Psychiatry/NYS Psychiatric Institute and the National Center on Addiction and Substance Abuse (CASA) to offer this uniform training.

This training is available to providers licensed by OMH and OASAS. CPI will make available provider profiles that document learning activities. Participation in this training program offers several advantages to providers, including:

• Training resources that are provided at no cost.
• Social work continuing education and CASA credits for clinical staff completing training for many of the training activities.
• Summary reports of training activities for providers to support internal continuous quality improvement activities.
• Provider profiles to help document staff clinical competencies and training activities to payers and partners. This documentation will be important as NYS continues to implement value-based reimbursement approaches.

We are writing at this time with some information relevant to the registration and trainings available in the CPI learning management system (LMS).

Registration:

• If you have not already registered, the enrollment survey is on the CPI website: www.practiceinnovations.org. Registration information will follow from CPI.
• Once registered, trainings are available in the CPI LMS.

Trainings will be offered in phases. The first phase is available now. You will be notified when each additional training is made available in the CPI LMS.

Our goal

Empire BlueCross BlueShield HealthPlus (Empire) is dedicated to improving the health of our members as well as empowering members and providers to make informed decisions. To support this goal, we are committed to improving care transitions for all members who experience an inpatient behavioral health admission. We want to better equip members and providers to address the individualized needs of our members as they are discharged from an inpatient psychiatric or substance-use level of care to an outpatient provider. Through the creation of a Discharge Action Plan (DAP) for our Health and Recovery Plan (HARP) members, we are systematically addressing important, member-specific elements of discharge planning including psychoeducation around medication management, triggers for symptom recurrence, identified coping skills and aftercare appointment instructions.

How is the DAP created?

Our inpatient care managers collaborate with facility social workers to collect information on care transitions and use this information to complete an individualized DAP for each HARP member. From the moment of first contact with the inpatient facility, our care managers work collaboratively with providers to gather the information necessary to prepare a thorough and robust discharge plan. We have reshaped our inpatient review process to focus on critical elements of discharge planning that can create barriers to member engagement and follow‑through with aftercare. Together, with the inpatient facility, we work to identify what structure needs to be in place for the member to be successful in the community, what self‑management skills the member endorses and what barriers might be present that would prevent the member from successfully recovering in their community. We actively gather this information throughout a member’s admission resulting in an individualized DAP for each HARP member that can be shared with the member, their provider and other member-identified community resources upon discharge.

How is the DAP used?

The DAP is a resource for the member as well as all providers and community supports who engage the member following discharge from an inpatient behavioral health level of care. When the member discharges from an inpatient admission, our team of dedicated outpatient care managers contact the outpatient provider identified for aftercare and fax them a copy of the individualized DAP. The dedicated case manager shares a copy with the member and the health home and/or care management agency working with the member. The goal in sharing the DAP is to educate providers about the member’s medications, coping skills and barriers to engagement and provide the member with a comprehensive self-help tool to guide them immediately following their discharge.

Providing innovative solutions

Furthermore, we are committed to providing innovative solutions to some of the health care industry’s greatest obstacles. We know that follow-through with aftercare is one of the most significant barriers facing our members and success in aftercare is one of the leading ways to prevent future readmissions. We also know that lack of integration between inpatient and outpatient care remains a major barrier for our providers. Through the creation and dissemination of our individualized DAP, we hope to eliminate obstacles, empower all those we work with to better meet the needs of our members and better serve the communities in which we live.

Each year, we may reach out to you to ask what we are doing well and how we can continue to improve our services. We use this feedback to continually improve our operations and strengthen our relationship with our providers.

Thank you for participating in our network, for providing quality health care to our members and for your timely completion of any surveys you receive.

We continually update our provider directories to ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice — including updating your address and/or phone number, adding or deleting a physician from your practice, closing your practice to new patients, etc. — please notify us by completing the Provider Maintenance Form. Thank you for your help and continued efforts in keeping our records up to date.

Managing illness can be a daunting task for our members. It is not always easy to understand test results or know how to obtain essential resources for treatment or who to contact with questions and concerns.

BlueShield HealthPlus is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, primary care physicians and caregivers. The Complex Case Management process utilizes the experience and expertise of the Case Coordination team to educate and empower our members by increasing self-management skills. The Complex Case Management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the Customer Service number located on the back of their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about health care decisions and goals.

You can contact us by email at casemanagementreferrals-nyc@anthem.com or nybhcasemanagement@empireblue.com for Behavioral Health Case Management. You can contact us by phone at
1-800-563-5909. Case Management business hours are Monday through Friday from 8 a.m. to 5 p.m. Eastern time.

Are you looking for innovative ways to improve your patients’ experiences and earn continuing medical education credits?

Numerous studies have shown that a patient’s primary health care experience and, to some extent, their health care outcomes are largely dependent upon health care provider and patient interactions. Empire BlueCross BlueShield HealthPlus (Empire) offers a new online learning course, What Matters Most: Improving the Patient Experience, to offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide and is acceptable for up to one prescribed continuing medical education credit by the American Academy of Family Physicians.

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices.

Did you know?

Substantial evidence points to a positive association between patient experience and health outcomes.

• Patients with chronic conditions, such as diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.
• Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.

How will this benefit you and your office staff? 

You’ll learn tips and techniques to:

• Improve communication skills.
• Build patient trust and commitment.
• Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey.

The course can be accessed at www.patientexptraining.com using your smartphone, tablet or computer.

Like you, Empire is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.

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

Use this guide for detailed information about pregnancy coding for risk factors, HEDIS® quality measures for prenatal and postpartum care, and ICD‑10-CM general coding and documentation. To access the full pregnancy coding guide on our website use this link.

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