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, 2019:

 

New for 2019:

• Claims Payment Disputes
• Medical Records Submission
• Reimbursement Guidelines and Policies

 

Updated for 2019:

• AIM Specialty Health
• Availity Portal
• Centers of Medical Excellence
• Claims Filing Tips
• Coordination of Benefits
• Credentialing
• EDI
• FEHBP
• Fraud Waste and Abuse Detection
• General Introduction
• HIX
• Medical Policy
• Medicare Advantage
• Multicultural Health
• Overpayment-Cost Containment
• Overview of CAHPS
• Overview of HEDIS®
• Pharmacy Home
• Quality Improvement
• Quality of Care Investigations
• Utilization Management

 

This quarter, empireblue.com will release more exciting enhancements to the public provider site. The next wave of changes includes a new Behavioral Health page that will provide easy and clear access to content and resources, including newsletters, collaboration documents, and other relevant information for providers. The image below illustrates the new Behavioral Health page.

 

We will continue to provide updates as we move forward with migrating content to the new provider pages.

 

Empire’s Find A Doctor tool provides Empire members with the ability to search for in-network providers using the member portal at empireblue.com. Find A Doctor currently offers multiple sorting options, such as sorting providers based on distance or name.

 

Beginning July 20, 2019, Empire’s Find A Doctor will have a new sorting option called “Personalized Match”. The sorting option is based on algorithms which will use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures. These member and provider features will be combined to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius will be displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius. Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.

 

As you may recall from our October 5, 2018 notice that this sorting option, “Personalized Match,” has been available on Care and Cost Finder since November 12, 2018, for Empire’s non-fully insured members. Now this sorting option will be available to all of Empire’s membership on the same terms and conditions as described in that October 5, 2018 notice.  

 

Additional information about Personalized Match:

• Provider factors will be updated on a quarterly basis.
• Providers may review a copy of the new sorting methodology here.
• If you have general questions about this new sorting option in Find A Doctor and the Care and Cost Finder tool, please contact Provider Customer Service.
• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.

 

Empire will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. 

As we prepare for potential regulatory proposed standards for electronic attachments, Empire will be implementing the X12 275 5010 version electronic attachments transactions for claims.

 

Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reduced processing time overall. 

 

Empire and Availity will be piloting EDI batch electronic attachments with previously selected providers.  Both solicited and unsolicited attachments will be included in our pilots.

 

Solicited Attachment- Provider sends a claim and Payer determines there is not enough information to process the claim.  Payer will then send the provider a request for additional information (currently via letter).  Provider can then send the solicited attachment transaction with the documentation requested to process the claim.

 

Unsolicited Attachment- When the provider knows that the payer requires additional information to process the claim, the provider will then send the X12 837 claim with the “Paper Work Included” (PWK) segment tracking number.  Then the provider will send the X12 275 attachment transaction with the additional information and include the tracking number that was sent on the claim for matching.

 

What you can do now:

Start having conversations with your Clearinghouse and/or Electronic Healthcare Records (EHR) vendor to determine their ability to set up the X12 275 attachment transaction capabilities. 

 

Look for more information around general availability of this exciting option later this summer with details on how to work with Empire and Availity to send your attachments via electronic batch.

Starting June 17, 2019, you will have a new way to check the status of a claim on the Availity Portal for Empire.  The link under the Claims & Payments menu is titled Claim Status and Remittance Inquiry. The options for Empire as a payer will no longer be available on the legacy claim status inquiry tool as of that date.

 

You may also use the Go To menu on the patient eligibility and benefit detail page to navigate seamlessly to the new look.

 

The new claim status look includes color coded patient ID cards and easy to read claim detail.

 

Secure Messaging Changes

A new Actions menu on the updated Claim Status page will be used to access the Secure Provider Messaging tool. The link Do you have a question about this claim? will no longer be available with the new claim screen. You can also use the Actions menu to edit or print the claim screen.

 

For more information on the changes, a Claim Status – Training webinar is coming mid-month.  Access the training Enroll link by logging in to the Availity Portal and selecting Help & Training | Get Trained.

Continuing our 2019 CRA updates, Empire requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes.

 

As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy.  We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.

 

This month we’d like to focus on the Retrospective approach, and the request to our Providers:

 

As a reminder from our March newsletter, the Retrospective Program focuses on medical chart collection.  We continue to request members’ medical records to obtain undocumented HCC’s. This particular effort is part of Empire’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership.  The members’ medical record documentation helps support this data requirement.

 

2019 chart collection is about to begin

Retrospective chart collection begins in June and is known as Round 1. Round 2 follows in November, which is our primary chase and largest volume of requests. Round 3 is our last chart collection period and begins in January, 2020.

 

Electronic options for chart collections

Submitting medical charts to payers is extremely burdensome and time consuming for your staff.  Utilizing an electronic option can alleviate the constraints on both staff resources and time.

 

Remote/Direct Empire Access

The most efficient electronic option is to allow the Empire medical coder team to have direct connection access to your EMR system, so that we may retrieve the records ourselves.  Our team has collaborated with several Providers and Facilities to have direct access to their EMR system so we collect the charts within our own team.  This allows for no vendor interventions and fewer handoffs of the records.  To address compliance concerns, please note that as a health plan, Empire is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI. 

 

Benefits of providing EMR direct connection access

• Your Medical Records staff resources would be minimally contacted for the charts we are requesting
• Depending on your EMR system, requests may also be handled electronically through “push” notifications
• Your Medical Records staff will release only those records we request into the EMR queue for which we have access
• Cost savings from less administrative impact on staff, as well as, no paper copying costs incurred
• Better privacy/security measures for not having to save the medical record to a desktop and then copy/save before transmittal

 

EMR Interoperability -- we have electronic options already in place for the following EMR systems:

• Allscripts (Opt in - signature required -- please work directly with the CRA Representative for your region)
• NextGen (Opt out - auto-enrolled)
• Athenahealth (Opt out - auto-enrolled)
• MEDENT (Opt in - signature required -- please work directly with the CRA Representative for your region)

 

Inovalon virtual visit or onsite -- Inovalon will work directly with your office to utilize electronic connectivity for a virtual visit, or they will have their staff go into the office for medical record retrieval based on a scheduled time that is convenient.

 

Secure FTP -- Set up directly with our vendors as a temporary secure FTP to transfer medical records. 

 

If you are interested in any of these electronic options, or would like to grant our Empire medical coders with direct access to your EMR, please contact our CRA Representative: Alicia.Estrada@anthem.com

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests that will begin soon.

To help ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis, we review clinical information, including lab results, treatment and medical management, in the medical records submitted.  In order to conduct the review accurately and consistently, our review process for sepsis diagnoses applies coding and documentation guidelines, in addition to the updated and most recent sepsis 3 clinical criteria, published in JAMA February 2016.  Clinicians and facilities should apply the sepsis 3 criteria when determining at discharge if their patient’s clinical course supports the coding and billing of a diagnosis of sepsis.  The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the sepsis 3 definition and criteria.

The Employee Health Plan of Suffolk County only provides coverage for lab services at a hospital based laboratory when billed with a covered surgery. If a lab test is not in conjunction with surgery, it is no longer considered a coverable service from this a hospital based lab. Lab services should be directed to a participating free standing laboratory. You can identify Suffolk County members by the prefix CDK or prefix SUF on the member identification card.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available at empireblue.com/provider/ > “Find Resources in New York” > Provider Home > Health and Wellness > Practice Guidelines.

Empire will implement the following clinical guideline effective July 1, 2019, to support the review for unnecessary inter-facility transfers. This guideline impacts our commercial PPO and HMO products.

 

The inpatient services addressed in this clinical guideline will require advance authorization prior to the inter-facility transfer.

 

Inpatient Inter-Facility Transfers (CG-ANC-07)

This guideline addresses the clinical features of a hospitalized individual who may require services unavailable at an initial acute care facility (originating facility) necessitating a transfer to a second acute care facility (receiving facility).

 

Inter-facility transfers are considered medically necessary when one or more of the following criteria are met:

• The individual requires a medically necessary diagnostic or therapeutic service (for example, organ transplantation) which is not available at the originating facility; or
• The individual requires a level of care (for example, neonatal care unit or level 1 trauma center) which is not available at the originating facility; or
• The individual requires the services of a specialist to evaluate, diagnose or treat his or her condition when that specialist is not available in a timely manner at the originating facility (Note: Timeliness of care is a case/individual specific attribute.  It may be appropriate for a medically stable individual to await availability of a specialist for several days while a medically unstable individual may require care more quickly); or
• The individual has received care at a specific prior institution for a condition not normally managed at the originating facility (for example, organ transplant recipient) and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue.

 

Inter-facility maternal transfer to allow birth mother to remain with neonate is considered medically necessary when neonate transfer meets the medically necessary criteria listed above and the birth mother requires continued hospitalization due to birth complications or other medically necessary conditions.

 

Inter-facility transfers between an originating facility and a receiving facility are considered not medically necessary when:

• The criteria above have not been met; or
• The services are primarily for the convenience of the individual, the individual’s family, the physician or the originating facility.

As previously communicated in the April 2019 edition of Empire’s Provider News, AIM Specialty Health® (AIM), a separate company, will begin to perform prior authorization review of rehabilitative (restoring function) and habilitative (enhancing function) services for Empire commercial fully insured members beginning July 1, 2019. Currently, OrthoNet LLC is performing medical necessity reviews for physical and occupational therapy services for Empire. These reviews, in addition to speech therapy service reviews, will transition to AIM. The AIM Rehabilitative Program began April 1, 2019 for Empire Medicaid members.

 

AIM will manage Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews and will require prior authorization for all outpatient facility and office-based rehabilitative and habilitative services following the initial evaluation. AIM will use the following [Brand] Clinical UM Guidelines:

• CG-REHAB-04 Physical Therapy
• CG-REHAB-05 Occupational Therapy
• CG-REHAB-06 Speech-Language Pathology Services

 

The clinical criteria used for these reviews can be found on our empireblue.com/provider Clinical UM Guidelines page. A complete list of CPT codes requiring prior authorization for the AIM Rehabilitative Program is available on the AIM Rehabilitation microsite. There you can access additional helpful information such as order entry checklists and FAQs.

 

AIM will now begin accepting prior authorization requests on June 24, 2019 for dates of service on and after July 1, 2019.  Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM 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.                                                                        

Need training?

Empire invites you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the robust capabilities of the AIM ProviderPortalSM.  Visit the AIM Rehab microsite to register for an upcoming training session.

Providers currently submit prior authorization requests to AIM Specialty Health® (AIM) for outpatient diagnostic imaging services, cardiac procedures and sleep studies. As part of our ongoing quality improvement efforts, we want you to know that certain review requests require documentation that supports the clinical appropriateness of the request to be uploaded during the intake process.

 

When requested, providers must submit documentation from the patient’s medical record and/or participate in a prior authorization consultation with an AIM physician reviewer. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. 

Category: Medicaid

Effective July 1, 2019, prior authorization (PA) requirements will change for the musculoskeletal procedure noted below. This procedure will now require PA for Empire BlueCross BlueShield HealthPlus 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 the following:

29892 — Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy)

 

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 at https://www.availity.com or at www.empireblue.com/nymedicaiddoc > Login. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 1-800-450-8753 for assistance with PA requirements.

Category: Medicare

Empire BlueCross BlueShield (Empire) has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, Empire will initiate postpay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

 

Empire will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Empire guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

 

Please note, these coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for nonemergencies, nor do they include the examination of emergent versus nonemergent reasons patients utilize emergency room services.

 

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Category: Medicaid

We’ve made it easy for you to access remittance advices online for all Empire BlueCross BlueShield HealthPlus (Empire) members using the new Remittance Inquiry tool on the Availity Portal.

 

How to access the remittance inquiry tool as of June 1, 2019

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

 

How it works

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

 

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

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

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

 

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

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

 

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

 

If you have questions about the tools and resources available within Payer Spaces or on the Empire website, contact Provider Services 1-800-450-8753 or your local Provider Relations representative.

Category: Medicare

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed.1 What can be done differently?

 

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

 

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

 

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

 

¹ Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm

 

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Category: Medicare

Please continue to check Important Medicare Advantage Updates at empireblue.com/medicareprovider for the latest Medicare Advantage information, including:

• Medicare risk adjustment provider training
• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ 
• Group Retiree members and National Access Plus
• Submitting corrected claims
• 2019 Utilization Management Affirmative Statement

 

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Category: Medicaid

Empire BlueCross BlueShield HealthPlus (Empire) has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, Empire will initiate postpay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

 

Empire will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Empire guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

 

Please note, these coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for nonemergencies, nor do they include the examination of emergent versus nonemergent reasons patients utilize emergency room services.

We’ve made it easy for you to access remittance advices online for all Empire members using the new Remittance Inquiry tool on the Availity Portal.

 

How to access the remittance inquiry tool as of June 1, 2019

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

 

How it works

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

 

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

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

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

 

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

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

 

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

 

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

 

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Category: Medicaid

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed1. What can be done differently?

 

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

 

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

 

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

 

¹ Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm

Category: Medicaid

In an effort to help your patients maintain healthy blood sugar levels throughout pregnancy, reduce the probability that babies will be born weighing greater than 4,500 grams and, thereby, reduce the potential for Cesarean section, Empire BlueCross BlueShield HealthPlus (Empire) offers the Diabetes in Pregnancy program to support you and your patients. Eligible Empire members in need of additional support may be enrolled in case management and referred to a registered dietitian/nutritionist or certified diabetes educator.

 

The program includes providing meal planning assistance, physical activity interventions, weight gain interventions and monitoring blood sugars patterns. Pregnant members with diabetes are identified as early as possible and are targeted for outreach to engage in case management.

 

Diabetes in pregnancy

The common types of diabetes seen during pregnancy are type 1, type 2 and gestational diabetes, which is defined as diabetes first diagnosed in the second or third trimester of pregnancy that is clearly neither pre‑existing type 1 or type 2 diabetes. According to the Centers for Disease Control and Prevention, pre‑existing diabetes occurs in 1% to 2% of all pregnancies and gestational diabetes in 6% to 9% of pregnancies.¹

 

While pregnancy complicated with diabetes is a low percentage of all pregnancies, the risk of Cesarean sections are much higher in this population than for women with uncomplicated pregnancies. Sixty-four percent of women with pre-existing diabetes and 46% of women with gestational diabetes will have a Cesarean section compared to 32% of women who do not have diabetes during pregnancy.²

 

Whether diagnosed with type 1 or type 2 diabetes or diagnosed with gestational diabetes, blood sugar control is essential for the health and well-being of mother and infant. All types of diabetes put the baby at risk for macrosomia, making a Cesarean section delivery more likely.3 Research indicates that early lifestyle interventions, such as meal planning and physical activity, can help women reach healthy blood sugar targets more quickly and help them stay in target longer, thus reducing the risk of macrosomia in the infant.³

According to the American College of Obstetricians and Gynecologists (ACOG), Cesarean sections should be limited to babies of at least 4,500 grams in mothers with diabetes.⁴

 

For more information

If you have a patient who would benefit from speaking with an Empire registered dietitian/nutritionist, certified diabetes educator or an obstetric case manager, please call Provider Services at 1-800-450-8753 and ask for a case management referral for the member.

 

If you would like more information on the Diabetes in Pregnancy program, please contact Provider Services at the number above.

 

¹ Retrieved from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/diabetes-during-pregnancy.htm.

² Agency for Healthcare Research and Quality Statistical Brief #102. Retrieved from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb102.jsp.

³ The New England Journal of Medicine, May 8, 2008 vol. 358 no. 19. Hyperglycemia and Adverse Pregnancy Outcomes, The HAPO StudyCooperative Research Group. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJMoa0707943.

⁴ Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomized trials. BMJ 2017;358:j3119 doi: 10.1136/bmj.j3119 (Published 19 July 2017).

Category: Medicaid

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.

 

Empire BlueCross 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 phone at 1-800-300-8181. Case Management business hours are Monday – Friday, 8:00 a.m – 5:00 p.m. and Saturday 9:00 a.m. – 5:00 p.m ET.

Category: Medicaid

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://www.empireblue.com/provider/policies.

 

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below. To access UM criteria online, go to https://www.empireblue.com/provider/policies.

 

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

 

You can submit precertification requests by:

• Calling us at 1-800-450-8753.
• Faxing to 1-800-964-3627.

 

Have questions about utilization decisions or the UM process?

Call our Clincial team at 1-800-450-8753 Monday – Friday, 8:00 a.m. – 7:00 p.m. ET.

Category: Medicaid

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Empire BlueCross BlueShield HealthPlus has adopted a Members’ Rights and Responsibilities Statement, which is located within the provider manual.

 

If you need a physical copy of the statement, call us at 1-800-450-8753.