One of the measures we report on is the Controlling High Blood Pressure (CBP) measure. This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).

 

What’s new for 2019?

• The Controlling High Blood Pressure (CBP) measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
• If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
• Compliant BP is defined as <140/90 mm Hg for all members.
• Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the Provider can be utilized for the measure.

 

What do we need from you?

We need the last 2 office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018 please send that documentation as well.

 

Common chart deficiencies:

• Recheck elevated blood pressures readings and document all BP readings in the medical record.

 

For more information on HEDIS go to empireblue.com/provider/ Select “Find Resources in New York” >Provider Home > Health & Wellness > Quality Improvement and Standards > HEDIS Information.

 

Thank you for your continued cooperation and support of HEDIS.

 

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

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.

A key goal of Empire’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Payment Innovation Providers”) in Empire’s various Payment Innovation Programs (e.g., Enhanced Personal Health Care, Bundled Payments, Medical Home programs, etc.) (the “Programs”) quality, utilization and/or cost information about the health care providers (“Referral Providers”) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Empire will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.

 

Have you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You will now find these changes that were recently introduced:

• Select the “Attachment – New” option to submit medical records when Empire has requested additional information to process a claim
• To send a solicited attachment, now find the “Send Attachment” link on the top, right side of the page
• Expanded file size – each attachment can be up to 40 MB with a total of 80 MB as the file size limit
• Ability to submit an itemized bill

 

If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Empire) medical record attachments through the Availity Portal.

 

The existing Medical Attachment tool will not be removed from the Availity Portal immediately but users are encouraged to connect to the ‘Attachment – New’ option for greater capabilities.

 

How to Access solicited Medical Attachments for Your Office

Availity Administrator, complete these steps:

 

From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:

1. Select Application>choose Medical Attachments Registration
2. Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs (Multiples can be added separated by spaces or semi-colons)
3. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name

 

Using Medical Attachments

Availity User, complete these steps:

1. Log in to www.availity.com
2. Select Claims and Payments > Attachments-New >Send Attachment Tab
3. Complete all required fields of the form
4. Attach supporting documentation
5. Submit

               

Need Training?

To access additional training for this Availity feature:

1. Log in to the Availity Portal at www.availity.com
2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
3. In the new window a list of available topics will open. Locate and click Medical Attachments
4. Under the Recordings section, click View Recording

 

Empire has designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway. The EDI Gateway is a no-cost option for our providers that choose to submit their own EDI claims to Empire.  If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.

 

As a mandatory requirement, all trading partners who currently submit directly to the Empire EDI Gateway must transition to the Availity EDI Gateway. 

 

Do you already have an Availity User ID and Login? You can use the same login for your Empire EDI transactions.  

• Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you. 

 

If you wish to become a direct a trading partner with Availity, the setup is easy.

• Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Empire EDI transmissions. 

 

Need Assistance?

 

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

 

835 Electronic Remittance Advice (ERA)

Please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.

 

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

 

If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time.

Empire launches additional changes to empireblue.com in March

This March, empireblue.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms, as seen below.

 

This first version of the new Provider Forms will keep growing and evolving in the coming months.

We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes.

Empire amends it’s Site of Service (SOS) reduction values from time to time to align with the annual updated list published by the Centers for Medicare & Medicaid Services (CMS). Empire’s SOS Reduction listing shows the percentage amount that we use for reducing physician reimbursement for selected procedures, when performed in a hospital inpatient, outpatient, emergency room or ambulatory surgical care facility

 

Effective April 1, 2019, we will be updating our SOS values to align with CMS’ Region 2 RBRVS calculations for 2018. To view the SOS Reduction listing for the 2018 values, please visit go to empireblue.com/provider/ Select “Find Resources in New York” >Provider Home > Site of Service (SOS) Reductions and view the percentages listed in the right hand column.

Effective April 1, 2019, Empire will update its HMO, EPO, PPO, Small Group, Individual and Indemnity fee schedules. The complete updated fee schedule will be available on Availity.com upon their effective date of April 1, 2019.

On April 1, 2017, the New York State Department of Health issued a revised version of the Provider Contract Guidelines for Article 44 MCOs, IPAs, and ACOs (“Provider Contract Guidelines”). According to the new Provider Contract Guidelines, managed care organizations must amend all existing participating provider agreements to include a new mandatory provision. Therefore, your existing agreement with Empire HealthChoice HMO, Inc. (d/b/a Empire BlueCross BlueShield HMO or Empire BlueCross HMO) and Empire HealthChoice Assurance, Inc. (d/b/a Empire Blue Cross BlueShield or Empire BlueCross) (collectively, “Empire”) is hereby unilaterally amended effective immediately to replace the “Regulatory Approval” provision of your Agreement with the following:

 

“Regulatory Approval. To the extent Provider participates in Networks under this Agreement, which are subject to review by the New York State Department of Health, this Agreement is subject to the approval of the New York State Department of Health as to form. If this Agreement is implemented prior to such approval, the parties agree to incorporate into this Agreement any and all modifications required by the Department of Health for approval or, alternatively, to terminate this Agreement if so directed by the Department of Health. The "New York State Department of Health Standard Clauses for Managed Care Provider/IPA/ACO Contracts", attached to the Agreement as Attachment A, are expressly incorporated into this Agreement and are binding upon the Article 44 plans and providers that contract with such plans, and who are a party to this Agreement. In the event of any inconsistent or contrary language between the Standard Clauses and any other part of the Agreement, including but not limited to appendices, amendments, exhibits, the parties agree that the provisions of the Standard Clauses shall prevail, except to the extent applicable law requires otherwise and/or to the extent a provision of the Agreement exceeds the minimum requirements of the Standard Clauses.”

 

To the extent that your Agreement contains Appendix A - New York State Department of Health Standard Clauses Appendix for Managed Care Provider/IPA Contracts , such Appendix A is deleted in its entirety and replaced with Attachment A - New York State Department of Health Standard Clauses for Managed Care Provider/IPA/ACO Contracts Revised April 1, 2017 attached .

Empire conducts an annual satisfaction survey of our Member’s behavioral health outpatient service experience.  The random survey is conducted based on receipt of claims.  We have recently reviewed the 2018 survey experience results and wanted to share highlights with our network of behavioral health providers.  The survey inquiries about the member’s satisfaction with timeliness of treatment, practitioner service/attitude and office environment, care coordination (among the member’s various providers), prescriptions/medication management process (if applicable), financial and billing process, and their perceived clinical improvement.   Our member is also asked to give an overall rating of the experience.  The 2018 overall practitioner rating was 93% in New York based on the survey results.

 

We were pleased to see overall improvement in the survey results.  In particular, two areas of focus over the last year, access and coordination of care.  Members responding to the survey, indicated that obtaining an appointment was fairly easy and many respondents indicated that care was being coordinated among their providers, including medical.  Care coordination and collaboration, particularly medical-behavioral integration, is a key focus at Empire.   We also encourage ongoing understanding of an individual’s cultural, spiritual and religious beliefs while in treatment.

 

While we are pleased with our member’s experience with our participating provider network and thank you for your network participation and the services you provide, we’d like to remind you of two key areas to maintain and improve satisfaction:

 

Member’s Access to Behavioral Health Care

As a participating provider please be reminded of Empire’s expectation, based on NCQA definitions, of access to behavioral healthcare to help ensure our members have prompt access to behavioral health care:

• Non-Life Threatening Emergency Needs - must be seen, or have appropriate coverage directing the Member, within 6 hours. When the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Urgent Needs - must be seen, or have appropriate coverage directing the Member, within 48 hours. Urgent calls concern members whose ability to contract for their own safety, or the safety of others may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. Urgent needs have the potential to escalate into an emergency without clinical intervention.
• Routine office visit - must be within 10 business days. Routine calls concern members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes.

 

We use several methods to monitor adherence to these standards.   Monitoring is accomplished by a) assessing the availability of appointments via phone calls and surveys by our staff or designated vendor to the provider’s office; b) analysis of member complaint data and c) analysis of member satisfaction.  Providers are expected to make best efforts to meet these access standards for all members.   Empire continues to look at gaps, barriers and alternative options to improve access to behavioral healthcare including tele-health services. 

 

Members Held Harmless

As a participating provider in Empire’s behavioral health provider network, a participating provider shall look solely to Empire for compensation for covered services and under no circumstances shall render a bill or charge to any member except for applicable co-payments, deductibles and coinsurance and for services that are not medically necessary or are otherwise not covered, provided that the Provider obtains the consent of the Member before providing such service. We recommend that consent be in writing and dated, in order to protect our members and providers from disputes.

 

In addition, Empire also reminds our participating providers that Empire members must be advised of missed or cancelled appointment policies at the onset of treatment.  We also recommend that the advisement be acknowledged by the member in writing, and that acknowledgement is dated. 

 

Thank you again for the services that you provide to our members.

Each year, Empire requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps. 

 

The CRA Program is specific to our Affordable Care Act (ACA) Members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

 

With our Retrospective Program we focus on medical chart collection.  We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS).  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.

 

Analytics are performed internally on claims which do not have the ICD-10 code for which we suspect a chronic condition.  These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Empire network providers -- may be PCPs, specialists, facilities, behavioral health, ancillary, etc. -- may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review.  These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf.  The vendors’ Web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. 

 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2019 at the latest).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

• EMR Interoperability
  • Allscripts (Opt in -- signature required)
  • NextGen (Opt out -- auto-enrolled)
  • Athenahealth (Opt out -- auto-enrolled)
  • MEDENT
• Remote/Direct Empire access
• Vendor virtual or onsite visit
• Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for Empire’s network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative: Alicia.Estrada@anthem.com.

 

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

Click here for additional information about Neonatal intensive care unit post-traumatic stress disorder program.

Click here for additional information about Accessing patient-specific drug benefit information through electronic medical records.

Click here for additional information about the Coding Spotlight: Cancer A provider’s guide to properly code cancers.

Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Click here for additional information about the Modifier 25 Reimbursement Policy Update.

Click here for additional information about Update: evaluation and management with Modifier 25.

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

• New clinical criteria web page for injectable, infused or implanted drugs covered under the medical benefit 
• 2019 risk adjustment provider training  
• New provider learning opportunity: Put the AIM ProviderPortal to work for you  
• New provider service phone number beginning January 1, 2019

 

75743MUPENMUB 01/24/2019

 

The following revised clinical criteria will be effective May 1, 2019. Visit www.empireblue.com/pharmacyinformation/clinicalcriteria.html to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

 

Clinical criteria effective date	Clinical criteria number	Clinical criteria	Clinical criteria (new/revised)
May 1, 2019	ING-CC-0001	Erythropoiesis Stimulating Agents	Revised
May 1, 2019	ING-CC-0004	H.P. Acthar Gel® (repository corticotropin injection)	Revised
May 1, 2019	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

75743MUPENMUB 01/24/2019

Empire updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

• Group code patient responsibility (PR) will be assigned.
• Claim adjustment reason codes (CARCs) will include the following:
  • o 1 — deductible amount (professional claim)
  • o 2 — coinsurance amount (professional claim)
  • o 3 — copay amount (professional and facility claim)
  • o 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
  • o 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
• Remittance advice remark codes (RARCs) will include the following:
  • o N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
  • o N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
  • o N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.

 

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

 

75743MUPENMUB 01/24/2019

In 2019, Empire is offering Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs).  D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These plans are $0 premium plans.  Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments.  Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

 

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

 

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.

 

For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

 

75743MUPENMUB 01/24/2019

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

 

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

 

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

 

If you have questions or feedback, please use this email link.