To help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions.

 

Submitting an itemized bill (unsolicited* medical attachment) for a high dollar claim just got easier!

 

To submit an itemized bill (unsolicited medical attachment):

1. Log in to Availity Portal
2. Select Claims & Payments | Attachments – New
3. Select Send Attachment
4. Under Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK. (see example below)

Providers can also submit a claim attachment using the Availity Portal for solicited** medical attachments.

 

Submit supporting documentation in response to a formal (solicited) request from the payer.

• Log in to Availity Portal
• Select Claims & Payments | Attachments – New
• Select Send Attachment
• Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number
• Add supporting documentation and Reason
• Submit

Additionally, if you attended a previous webinar, we have updated information on submitting an EDI 837 batch that includes a PWK segment in loops 2300/2400. The update is regarding the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.

 

What does this mean for you?

You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim and no additional face sheet or coversheet is needed.

 

Here are the steps:

• Log in to Availity Portal
• Select Claims & Payments I Attachments - New
• From the Inbox tab, select the appropriate claim or open the request in your work queue
• Add files with supporting documentation
• Submit

Get Trained

• Attend an Availity hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity here

OR

• Log into Availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).

• Search by keyword (Medattach) to find on-demand and live training options
• Click Enroll to enroll for a course and then go to your Dashboard to access it any time

 

Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.

 

*Unsolicited attachment: Documentation submitted without a formal request from the payer

**Solicited attachment: Documentation submitted in response to a specific request from payer

 

1017-0321-PN-NY

Empire BlueCross BlueShield (“Empire”) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

 

Effective with dates of service on or after June 1, 2021, medical necessity review of the site of care is required for the following long-acting colony-stimulating factors for oncology indications for Empire commercial plan members.  

 

• Neulasta® & Neulasta Onpro® (pegfilgrastim)
• Fulphila® (pegfilgrastim-jmdb)
• Udenyca® (pegfilgrastim-cbqv)
• Ziextenzo® (pegfilgrastim-bmez)
• Nyvepria™ (pegfilgrastim-apgf)

 

The review will be administered by AIM Specialty Health_® (AIM).

 

AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Empire’s Medical Policy and Clinical UM Guideline page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.

 

The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.

 

Submit a request for review

Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:

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

 

Please note, this review does not apply to the following plans: BlueCard_®, Federal Employee Program_® (FEP_®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com/provider.

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the member’s ID card.  

 

Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “site of care.”

 

1019-0321-PN-NY

 

Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

Empire is committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Empire has the answers before you ask the questions. With an initial focus on claim-level insights, Empire has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.

Access the Claims Status Listing on Payer Spaces from https://www.empireblue.com/nymedicaiddoc by  using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

 

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

 

Empire made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

 

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Empire is using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield.

 

NYE-NU-0278-20 January 2021                                                                                                                 

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Effective June 1, 2021, the following new customizations will be implemented:

• Gastrointestinal Bleeding, Upper (W0170, previously ORG M-180) — Customized the Clinical Indications for admission to inpatient care by revising the hemoglobin; systolic blood pressure; pulse; melena; orthostatic hypotension; and BUN criteria.
• Gastrointestinal Bleeding, Upper Observation Care (W0171, previously OCG OC-021) — Customized the Clinical Indications for observation care by revising the systolic blood pressure and hemoglobin criteria and adding melena or hematochezia and suspected history of bleeding.

 

To access a detailed summary of customizations, select: Customizations to MCG Care Guidelines 24th Edition (path: visit https://www.empireblue.com/provider/policies/clinical-guidelines > Other Criteria > MCG > Customizations to the MCG Care Guidelines 24th Edition.)

 

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.

 

NYE-NU-0282-20 January 2021

Why are these changes necessary?

Changes are meant to simplify code selection criteria, make coding more clinically relevant and to reduce documentation overload for office-based evaluation and management (E/M) services, while continuing to differentiate payment based on complexity of care.

Key elements of major revisions for 2021:

• Physicians may choose their documentation based on medical decision making (MDM) or total time (including non-face-to-face services).
• History and exam are still important parts of the notes and may contribute to both time and MDM, but they will no longer be scored for determining the level of the E/M
• MDM criteria has moved away from simply adding up tasks to instead focusing on tasks that affect the management of a patient’s
• Code 99201 was
• Codes 99202 to 99215 were revised.

 

Changes to time documentation

Time will now be defined as the total time spent by the provider (both face-to-face and time spent on

non-face-to-face activities related to this patient’s visit performed on the same day as the visit). This may include the services listed below but should not include time spent on separately billable services (such as X-ray interpretation). Effective January 1, 2021:

• The total time spent must be documented clearly by the provider for the E/M level to be determined by time and does not include ancillary staff
• Time will no longer need to be dominated by
• All time used for leveling the E/M must be on the same day as the face-to-face visit.

 
Services included in total time:

• Preparing for the visit (for example, reviewing test results)
• Obtaining and/or reviewing separately obtained history
• Performing a medically necessary examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering tests, medications, prescriptions or procedures after the visit
• Referring and communicating with other health care professionals (when not reported separately)
• Documenting clinical information in the patient’s medical record
• Independently interpreting results (not separately reportable) and communicating results to the patient/family/caregiver
• Care coordination (not separately reportable)

 

New patient E/M code	Typical time (2020)	Total time (2021)
99201	10 minutes	Code deleted
99202	20 minutes	15 to 29 minutes
99203	30 minutes	30 to 44 minutes
99204	45 minutes	45 to 59 minutes
99205	60 minutes	60 to 74 minutes

 

Established patient E/M code	Typical time (2020)	Total time (2021)
99211	5 minutes	Time component removed
99212	10 minutes	10 to 19 minutes
99213	15 minutes	20 to 29 minutes
99214	25 minutes	30 to 39 minutes
99215	40 minutes	40 to 54 minutes

 

Prolonged office services

2021 changes include addition of a new add-on code (currently labeled 99417) for prolonged office visits when time is used for code level selection, including face-to-face and non-face-to-face provider time of at least 15 additional minutes on the same date of service for level five office visits (99205, 99215).

 

Medical decision making (MDM)

Using the new MDM table, medical decision making for office/outpatient visits will be based on meeting (or exceeding) two out of three categories:

 

MDM must meet two out of three elements
Code	Level of MDM	Number and complexity of problems addressed	Amount and/or complexity of data to be reviewed and analyzed	Risk of complications and/or morbidity or mortality of patient management
99211	N/A	N/A	N/A	N/A
99202 99212	Straightforward	Minimal	Minimal or none	Minimal
99203 99213	Low	Low	Limited	Low
99204 99214	Moderate	Moderate	Moderate	Moderate
99205 99215	High	High	Extensive	High

 

Number and complexity of problems addressed at the encounter:

• Straightforward: One self-limited or minor problem
• Low: Two or more self-limited or minor problems; one stable chronic illness, one acute, uncomplicated illness or injury
• Moderate: One or more chronic illnesses with exacerbation, progression or side effects of treatments; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; one acute complicated injury
• High: One or more chronic illnesses with severe exacerbation, progression or side effects of treatment; one acute or chronic illness or injury that poses a threat to life or bodily function.

 

Amount and/or complexity of data to be reviewed and analyzed

The 2021 guidelines list three categories for data:

1. Tests, documents or independent historians.
2. Independent interpretation of tests
3. Discussion of management or test interpretation.

 

• Straightforward: Minimal or none
• Low (one category required):
  • Two tests/documents or independent historian
• Moderate (one category required):
  • Three tests, documents and/or independent historian
  • Independent interpretation of a test
  • Discussion of management or test interpretation
• High (two categories required):
  • Three items between documents and independent historian
  • Independent interpretation of a test
  • Discussion of management or test interpretation

 

Risk of complications and/or morbidity or mortality of patient management

For the purposes of MDM, level of risk is based upon the consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization:

• Minimal: Rest, gargle, elastic bandages, superficial dressings
• Low: OTC drugs, physical therapy, minor surgery with no identified risk factors, IV fluids without additives
• Moderate: Management of a prescription drug, minor surgery with identified risk factors, decision regarding major surgery without identified risk factors, diagnosis or treatment
• High: Need to discuss higher risk problems that could happen for which physician or other qualified health care professional will watch or

 

Tips to prepare your practice for E/M office visit changes:

• Identify project lead
• Schedule team preparation time
• Update practice protocols
• Consider coding support
• Review business liability coverage
• Guard against fraud/abuse
• Update compliance plan
• Check with your electronic health record (EHR) vendor
• Assess financial impact
• Understand medical liability coverage

 

Resources:

• CPT^® Professional Edition, 2021. AMA
• AMA Elements of Medical Decision Making. https://www.ama-assn.org/system/files/2019-06/cpt-revised- mdm-grid.pdf
• AMA Press Release 2021 CPT code https://www.ama-assn.org/press-center/press-releases/ama-releases- 2021-cpt-code-set
• Major E/M Changes Coming Are you prepared? https://www.aapc.com/evaluation-management/em- codes-changes-2021.aspx

 

NYE-NU-0287-20 January 2021

 

Effective for dates of service on and after April 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria noted below will be included in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review.

 

Clinical Criteria	Status	Drug(s)	HCPCS codes
ING-CC-0011	Nonpreferred	Ocrevus®, injection, 1 mg	J2350
ING-CC-0160	Nonpreferred	Eptinezumab, injection 1 mg	J3032

 

The Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative.

 

NYE-NU-0288-20 January 2021

Empire BlueCross BlueShield will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

 

We encourage providers who offer telehealth services to use the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.

 

Visit https://www.empireblue.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

 

EBSCRNU-0151-20 January 2021

516908MUPENMUB

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

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

 

To view a guideline, visit https://www11.empireblue.com/ny_search.html.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
  • Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
• *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
  • Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
• *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
  • Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
  • Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
• *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
  • Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
• *CG-LAB-15 – Red Blood Cell Folic Acid Testing
  • RBC folic acid testing is considered not medically necessary in all cases
• *CG-LAB-16 – Serum Amylase Testing
  • Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
• *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
• Added the Afirma Xpression Atlas as not medically necessary
• 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
  • A new Medical Policy was created from content contained in DME.00011.
  • There are no changes to the policy content.
  • Publish date is December 16, 2020.
• CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
  • A new Clinical Guideline was created from content contained in GENE.00026.
  • There are no changes to the guideline content.
  • Publish date is December 16, 2020.

 

Medical Policies

On November 5, 2020, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield (Empire). These guidelines take effect March 8, 2021.

 

Publish date	Medical Policy number	Medical Policy title	New or revised
12/16/2020	*GENE.00055	Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity	New
12/16/2020	*LAB.00037	Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)	New
11/12/2020	ANC.00009	Cosmetic and Reconstructive Services of the Trunk and Groin	Revised
12/16/2020	*DME.00011	Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices	Revised
11/12/2020	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
11/12/2020	MED.00129	Gene Therapy for Spinal Muscular Atrophy	Revised
12/16/2020	SURG.00011	Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
12/16/2020	*SURG.00062	Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele	Revised

 

Clinical UM Guidelines

On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines were adopted by the medical operations committee for Empire members on November 19, 2020. These guidelines take effect March 8, 2021.

 

Publish date	CUMG number	CUMG title	New or revised
12/16/2020	*CG-LAB-15	Red Blood Cell Folic Acid Testing	New
12/16/2020	*CG-LAB-16	Serum Amylase Testing	New
11/12/2020	CG-DME-42	Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices	Revised
12/16/2020	*CG-GENE-04	Molecular Marker Evaluation of Thyroid Nodules	Revised
12/16/2020	CG-GENE-18	Genetic Testing for TP53 Mutations	Revised
12/16/2020	CG-GENE-20	Epidermal Growth Factor Receptor (EGFR) Testing	Revised
11/12/2020	CG-MED-87	Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications	Revised

 

EBSCRNU-0153-21 January 2021

517123MUPENMUB

 

Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

 

Empire is committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Empire has the answers before you ask the questions. With an initial focus on claim-level insights, Empire has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.

Access the Claims Status Listing on Payer Spaces from https://www.empireblue.com/nymedicaiddoc by  using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

 

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

 

Empire made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

 

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Empire is using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield.

 

NYE-NU-0278-20 January 2021                                                                                                                 

516792MUPENMUB

 

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

• MCG Care Guidelines 24th edition customization
• DME Checklist of Information Needed from Providers