 Provider News New YorkMarch 2022 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We are asking you to review your online provider directory information on a regular basis to ensure it is correct. Access your information by visiting empireblue.com/provider, then under Provider Overview, choose Find Care.
Submit updates and corrections to your directory information using our online Provider Maintenance Form. Online update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
Once you submit the form, we will send you an email acknowledging receipt of your request.
The Consolidated Appropriations Act (CAA) contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. By reviewing your information regularly, you can help us ensure your online provider directory information is current
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Colorectal cancer is the most common cause of cancer death among Asian Americans 1, while African Americans are 40% more likely to die from the disease than any other racial or ethnic group 2 in the United States. There are many possible reasons for the differences in survival rates among these racial and ethnic groups, but the common thread between them both is screening. For African Americans and Asian Americans the reluctance could be cultural. They may not be as likely to ask about the screenings as their White counterparts.
Resources to help talk to patients about colorectal cancer screening
The Centers for Disease Control and Prevention website is an excellent resource for information about colorectal cancer that you can share with your patients. There is even a quiz to help your patients understand the importance of screening as a prevention.
We’ve also developed two videos for you to play in your patient waiting room, share with patients in the exam room, or share the link through your digital schedulers.
Colorectal cancer screening for African Americans
Colorectal Screening for Asian Americans
Measure up: HEDIS ® measures members ages 50–75 who receive the appropriate screening for colorectal cancer.
There are multiple test types that meet the requirement:
- Screening colonoscopy every 10 years
- Screening flexible sigmoidoscopy every 5 years
- Computed tomography (CT) colonography every 5 years
- Screening fecal occult blood test (FOBT) annually
- FIT DNA (i.e. Cologuard®) at home testing every 3 years
Coding Tips
For screening, use the appropriate code:
|
Screening
|
Commonly used billing codes
|
|
Flexible sigmoidoscopy
|
CPT: 45330–45335, 45337–45342, 45346, 45347, 45349, 45350
HCPC: G0104
|
|
FIT-DNA (i.e. Cologuard®)
|
CPT: 81528
|
|
Occult blood test
(FOBT, FIT, guaiac)
|
CPT: 82270, 82274
HCPC: G0328
|
|
Colonoscopy
|
CPT: 44388–44394, 44401–44408, 45378–45386, 45398, 45388–45693
HCPC: G0105, G0121
|
|
CT Colonography
|
CPT: 74261, 74262
|
For exclusions, use the appropriate ICD-10 code:
|
ICD-10
|
Description
|
|
Z85.038
|
Personal history of other malignant neoplasm of large intestine
|
|
Z85.048
|
Personal history of other malignant neoplasm of rectum, rectosigmoid junction and anus
|
|
Z51.5
|
Encounter palliative care
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Patients say they more likely to have a cancer screening when their physician recommends it. What else can you do to influence cancer screenings? 1
- Understand the power of the physician recommendation.
- Your recommendation is the most influential factor in whether a person decides to get screened.
- Patients are 90% more likely to get a screening when they reported a physician recommendation.
- “My doctor did not recommend it,” is the primary reason for screening avoidance.
- Recognize cultural barriers that may impact your diverse patients
- Culturally sensitive conversations with your patients can help with fear, embarrassment, anxiety, and misconceptions about screenings.
- Go to mydiversepatients.com for information and resources.
- Measure the screening rates in your practice; it may not be as high as you think.
- Set goals to get screening rates up.
-
- Follow the HEDIS® guidelines included in this article to help accurately track your care gap closures.
- More screening doesn’t have to mean more work for you.
- Reach out to us about available member data – we may be able to help identify or supply access to data for those members who are due screenings.
- Develop a reminder system, which has been demonstrated to be effective, to remind you and staff that patients have screenings due.
- Help members access benefit information about screenings to eliminate the cost barrier.
- Log onto availity.com and use the Patient Information tab to run an Eligibility and Benefits inquiry.
- Members can access their benefit information by logging onto empireblue.com, through Live Chat, or by downloading the Sydney Health App.
- Blue Cross Blue Shield Service Benefit Plan members, also known as Federal Employee Program® members, can access their benefit information by logging onto fepblue.org, or by downloading the fepblue App from the Apple Store or on Google Play.
Measure Up: Cancer Screening for Women HEDIS® Measure Specifications
Organized and continuous screenings along with removal of precancerous lesions can lead to a 60% decrease in cervical cancer.2
Cervical Cancer Screening (CCS) is measured by the percentage of women 21 to 64 years of age who were screened for cervical cancer using either of the following criteria:
- Women 21–64 years of age who had cervical cytology performed within the last 3 years.
- Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
- Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years.
|
Description
|
Code
|
|
Cervical cytology lab test
|
CPT: 88141–88143, 88147, 88148, 88150, 88152–88153, 88164–88167, 88174, 88175
HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091
LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
|
|
hrHPV lab test
|
CPT: 87620–87622, 87624–87625
HCPCS: G0476
LOINC: 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0
|
|
Absence of cervix diagnosis
|
ICD-10-CM: Q51.5, Z90.710, Z90.712
|
|
Hysterectomy with no residual cervix
|
CPT: 51925, 56308, 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58951, 58953, 58954, 58956, 59135
ICD-10-PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On January 10, 2022, updated Preventive Care Guidance was released by the Departments of Labor, Health and Human Services (HHS), and the Treasury. This new guidance (referenced on page 11) applies to most of Empire BlueCross BlueShield’s ACA-complaint non-grandfathered health plans when services are provided in-network. This new guidance indicates:
On May 18, 2021, the USPSTF updated its recommendation for colorectal cancer screening. The USPSTF continues to recommend with an “A” rating screening for colorectal cancer in all adults aged 50 to 75 years and extended its recommendation with a “B” rating to adults aged 45 to 49 years. In its “Practice Considerations” section detailing screening strategies, the Final Recommendation Statement provides: “When stool-based tests reveal abnormal results, followup with colonoscopy is needed for further evaluation…. Positive results on stool-based screening tests require follow-up with colonoscopy for the screening benefits to be achieved.” Additionally, the Final Recommendation Statement provides with respect to direct visualization tests: “Abnormal findings identified by flexible sigmoidoscopy or CT colonography screening require follow-up colonoscopy for screening benefits to be achieved.”
For a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization screening test for colcorectal cancer, in-network providers should code the claim as a screening colonoscopy rather than as a diagnostic colonoscopy.
Providers can contact the provider service number on the back of the member ID card to determine if a member’s plan includes this benefit.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Consumer surveys show that doctors are the most persuasive and influential source of information around vaccines. Empire BlueCross BlueShield (“Empire”) is working to make it easier for physicians to offer their strong recommendations for vaccinations – especially vaccines for COVID-19 and influenza.
Empire recently launched a single page to host resources for health care professionals related to vaccination, including a guide to talking with reluctant patients to respond to common concerns, and one comparing flu and COVID-19 vaccines.
We will continue to refresh and add to available content on the new vaccination resource page.
Visit our website for the most up to date COVID-19 information from Empire.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We appreciate the feedback you shared about the Availity multi-payer Authorization application. Thanks to the insight about your user experience, we’ve made enhancements that we hope will improve your experience even more.
Submissions through Interactive Care Reviewer (ICR)
We appreciate the input you provided about the landing page to the ICR application. The landing page was designed to make it easier to navigate to ICR, but we heard it was confusing. We have made a correction to the landing page making it easier to understand and to navigate to ICR for:
- Behavioral health member authorizations and inquiries
- Appeals
- Federal Employee Program member submissions
- Medical specialty pharmacy authorizations and inquiries.
Tip: As a reminder, you will receive an error message if you submit an authorization through Availity when it should have been submitted through ICR. This is another way to ensure your authorizations are being processed accurately. If an authorization is submitted through Availity and it should have been submitted through ICR, it will not process correctly and could cause delays in patient care.
Authorization Reference Number Latency
The amount of time it took to receive your authorization reference number was prolonged during the initial launch period. While it may have taken a few extra minutes, this did not prevent you from continuing to submit additional authorizations while waiting for an authorization reference number. Access your authorization reference number at any time from your dashboard. You can also sort, filter and check the status of your authorizations from your dashboard.
Continue to share your experience
We are updating and making enhancements to the Empire BlueCross BlueShield experience in the Availity multi-payer Authorization application based on your input and feedback. If you are experiencing an issue using the application, reach out to Availity Client Services at 1-800-282-4548. Screen shots, case information, dates of service are all helpful pieces of information to assist the service team in identifying and correcting the issues.
Become an Availity user today
If you aren’t registered to use Availity, signing up is easy and 100% secure. There is no cost for our providers to register or to use any of the digital applications. Start by logging onto Availity.com and selecting the Register icon at the top of the home screen or use this link to access the registration page.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the months ahead, you will notice that our correspondence to you has changed. We’ve simplified our requests for additional information by providing exactly the information you need to know, enabling quicker claims processing and faster payments.
Enabling digital responses
Our new correspondence format includes the easiest, fastest, and most efficient way to return the information requested. We’ll provide you with instructions about how to submit the information digitally. Whether it is through the Claims & Payments application for resubmission or by using the Attachments application, it is all in one place and accessible by logging onto Availity.com.
Digital responses to our request for additional information is one of the ways we can work together to reduce the amount of time and expense associated with claims processing.
Become an Availity user today
If you aren’t registered to use Availity, signing up is easy and 100% secure. There is no cost for our providers to register or to use any of the digital applications including our correspondence to you. Start by logging onto Availity.com and selecting the Register icon at the top of the home screen or use this link to access the registration page.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Effective for dates of service on and after June 12, 2022, the following updates will apply to the AIM Specialty Health® (AIM)* Outpatient Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates focus on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.
Physical therapy and occupational therapy:
- Removed definition of evidence-based therapy and added definition for functional progress
- Added examples of the following:
- Appropriate goals
- Skilled intervention documentation
- Clinically meaningful improvement and functional progress
- Rehabilitation purpose
Speech-language pathology:
- Removed definition of evidence-based therapy and added definition for functional progress
- Added examples of the following:
- Appropriate goals
- Functional progress
- Rehabilitation purpose
Physical therapy and occupational therapy adjunctive treatments:
- Removed dry needling indication
- Edited exclusions
As a reminder, ordering and servicing providers must submit prior authorization requests to AIM in one of the following methods:
- Access AIM’s 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* Portal at availity.com.
- Call the AIM Contact Center toll-free number at: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
If you have 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 and upcoming guidelines on the AIM website.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Empire BlueCross BlueShield (“Empire”) Federal Employee Program is making an address change for the clinical grievance and appeal submissions to help accommodate recent office environment and staffing changes.
The new address is effective immediately and should be used for all clinical grievance and appeal submissions, including new requests and medical records for existing requests.
Old Address:
FEP Appeals
3075 Vandercar Way
Cincinnati OH 45209
NEW Address:
FEP Appeals
PO Box 105318
Atlanta, GA 30348
The fax number for clinical appeals for the Empire Federal Employee Program remains the same at
1-855-207-9935.
If you have any questions, please contact FEP customer service at: 800-522-5566.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Reveleer is the contracted vendor to gather member medical records on behalf of the Empire BlueCross BlueShield Federal Employee Program. We value the relationship with our providers and ask that you respond to the detailed requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe.
Reveleer will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary). We ask that you comply promptly within five (5) business days of the record requests. If you have any questions, you can reach a Reveleer representative by calling 855-454-6182 or contact Ify Ifezulike with Empire BlueCross BlueShield Federal Employee Program at (419) 494-6954.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Specialty pharmacy updates for Empire BlueCross BlueShield (“Empire”) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after June 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0062
|
Hulio
Ixifi
|
J3590
Q5109
|
|
*ING-CC-0205
|
Fyarro
|
J3490
J3590
|
|
*ING-CC-0206
|
Besremi
|
J3490
J3590
|
|
ING-CC-0207
|
Vyvgart
|
C9399
J3490
J3590
|
|
ING-CC-0208
|
Adbry
|
J3490
|
|
ING-CC-0209
|
Leqvio
|
J3490
|
|
ING-CC-0004
|
Purified Cortrophin Gel
|
J3490
J3590
|
* Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after March 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be removed from our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Mvasi
Zirabev
|
Q5107
Q5118
|
Quantity limit updates
Effective for dates of service on and after June 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
*ING-CC-0206
|
Besremi
|
J3490
J3590
|
|
ING-CC-0207
|
Vyvgart
|
C9399
J3490
J3590
|
|
ING-CC-0208
|
Adbry
|
J3490
|
|
ING-CC-0209
|
Leqvio
|
J3490
|
*Oncology use is managed by AIM.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Correction: In the February 2022 edition of Provider News, we published updates for the drugs Tivdak, Byooviz and Skytrofa. Please be advised that the effective date for these updates have changed.
Previous effective date: May 1, 2022
Updated effective date: June 1, 2022
Below is the updated notice.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire BlueCross BlueShield’s (“Empire”) medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after June 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
*ING-CC-0204
|
Tivdak
|
J3490, J3590, J9999
|
|
ING-CC-0072
|
Byooviz
|
J3490
|
|
ING-CC-0068
|
Skytrofa
|
J3490
|
* Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after June 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Non-Preferred
|
Byooviz
|
J3490
|
Quantity limit updates
Effective for dates of service on and after June 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Byooviz
|
J3490
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Empire BlueCross BlueShield’s pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.
The following clinical criteria documents were endorsed at the December 13, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.
Archived clinical criteria effective December 30, 2021
The following clinical criteria document has been archived.
- ING-CC-0181 Veklury (remdesivir)
New clinical criteria effective January 4, 2022
The following clinical criteria are new.
- ING-CC-0205 Fyarro (sirolimus albumin bound)
- ING-CC-0206 BESREMi (ropeginterferon alfa-2b-njft)
New clinical criteria effective January 17, 2022
The following clinical criteria are new.
- ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)
- ING-CC-0208 Adbry (tralokinumab)
- ING-CC-0209 Leqvio (inclisiran)
Revised clinical criteria effective January 28, 2022
The following clinical criteria was revised to expand medical necessity indications or criteria.
- ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
Revised clinical criteria effective January 31, 2022
The following clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0015 Infertility and HCG Agents
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0079 Strensiq (asfotase alfa)
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0168 Tecartus (brexucabtagene autoleucel)
Revised clinical criteria effective January 31, 2022
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0018 Agents for Pompe Disease
- ING-CC-0154 Givlaari (givosiran)
- ING-CC-0185 Oxlumo (lumasiran)
- ING-CC-0190 Nulibry (fosdenopterin)
- ING-CC-0198 Relizorb (immobilized lipase) cartridge
Revised clinical criteria effective June 1, 2022
The following clinical criteria was revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0004 Repository Corticotropin Injection
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Empire BlueCross BlueShield. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following codes:
- K1022 — Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type
Not all PA requirements are listed here. PA requirements are available to contracted providers on the provider website at https://www.empireblue.com/medicareprovider > Login or by accessing Availity.* Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the member’s ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On September 22, 2021, and November 19, 2021, the Pharmacy and Therapeutics (P&T) committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised, or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.
See the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Share this notice with other members of your practice and office staff.
Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
|
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
|
March 9, 2022
|
*ING-CC-0204
|
Tivdak (tisotumab vedotin-tftv)
|
New
|
|
March 9, 2022
|
*ING-CC-0018
|
Lumizyme (alglucosidase alfa); Nexviazyme (avalglucosidase alfa-ngpf)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0128
|
Tecentriq (atezolizumab)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0012
|
Brineura (cerliponase alfa)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0021
|
Fabrazyme (agalsidase beta)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0017
|
Xiaflex (collagenase clostridium histolyticum)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0026
|
Testosterone Injectable
|
Revised
|
|
March 9, 2022
|
*ING-CC-0100
|
Istodax (romidepsin)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
|
March 9, 2022
|
ING-CC-0197
|
Jemperli (dostarlimab-gxly)
|
Revised
|
|
March 9, 2022
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0061
|
GnRH Analogs for the Treatment of Non-Oncologic Indications
|
Revised
|
|
March 9, 2022
|
*ING-CC-0148
|
Agents for Hemophilia B
|
Revised
|
|
March 9, 2022
|
*ING-CC-0149
|
Select Clotting Agents for Bleeding Disorders
|
Revised
|
|
March 9, 2022
|
*ING-CC-0065
|
Agents for Hemophilia A and von Willebrand Disease
|
Revised
|
|
March 9, 2022
|
ING-CC-0168
|
Tecartus (brexucabtagene autoleucel)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0195
|
Abecma (idecabtagene vicleucel)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0001
|
Erythropoiesis Stimulating Agents
|
Revised
|
|
March 9, 2022
|
*ING-CC-0173
|
Enspryng (satralizumab-mwge)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0170
|
Uplizna (inebilizumab-cdon)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0041
|
Complement Inhibitors
|
Revised
|
|
March 9, 2022
|
*ING-CC-0071
|
Entyvio (vedolizumab)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0064
|
Interleukin-1 Inhibitors
|
Revised
|
|
March 9, 2022
|
*ING-CC-0042
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
|
March 9, 2022
|
*ING-CC-0066
|
Monoclonal Antibodies to Interleukin-6
|
Revised
|
|
March 9, 2022
|
*ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
|
March 9, 2022
|
*ING-CC-0078
|
Orencia (abatacept)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0063
|
Stelara (ustekinumab)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0062
|
Tumor Necrosis Factor Antagonists
|
Revised
|
|
March 9, 2022
|
ING-CC-0003
|
Immunoglobulins
|
Revised
|
|
March 9, 2022
|
*ING-CC-0049
|
Radicava (edaravone)
|
Revised
|
|
March 9, 2022
|
*ING-CC-0075
|
Rituximab Agents for Non-Oncologic Indications
|
Revised
|
|
March 9, 2022
|
*ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
|
March 9, 2022
|
ING-CC-0107
|
Bevacizumab for Non-Ophthalmologic Indications
|
Revised
|
|
March 9, 2022
|
ING-CC-0106
|
Erbitux (cetuximab)
|
Revised
|
|
March 9, 2022
|
ING-CC-0105
|
Vectibix (panitumumab)
|
Revised
|
|
March 9, 2022
|
ING-CC-0043
|
Monoclonal Antibodies to Interleukin-5
|
Revised
|
|
March 9, 2022
|
*ING-CC-0068
|
Growth Hormone
|
Revised
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Medication adherence improves overall member health and reduces hospitalizations. According to the World Health Organization, “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments .” 1
Did you know?
- Most medication-related ER visits and hospitalizations in the U.S. (up to 70%) are caused by
nonadherence to medication.2
- Studies show that 50 to 60% of patients are not taking their prescribed medications correctly or at all.3
- Improved adherence can drive positive health and economic outcomes.
- Patients’ adherence to statin medications at 12 months had improved LDL, reduced hospitalizations, and lower healthcare costs.4
Best practices for improving adherence
Support the implementation of medication nonadherence prevention strategies at each step of the medication use process:
- Prescribe maintenance medications for diabetes, cholesterol, and hypertension from the Empire BlueCross BlueShield (Empire) Medicare Advantage $0 copay list.
- Encourage IngenioRx* Home Delivery to improve medication adherence, prevent refill gaps, avoid long waits at the pharmacy, and to reduce costs.
- IngenioRx Home Delivery members have 2 to 3% higher adherence rates
- E-prescribe, fax 800-378-0323, or phone-in prescriptions 833-203-1742
- Enrolled nonadherent patients may benefit from a multi-dose packaging of medications. CVS pharmacy® SimpleDose™ and PillPack are preferred pharmacies that offer multi-dose packaging with free home delivery. To enroll, go to:
- CVS.com/multidose or call 800-753-0596. Members may also enroll at their local CVS pharmacy. Members residing in the District of Columbia, Georgia, or South Carolina should call 844-650-1637.
- Pillpack.com/blue or call 866-282-9462.
- Offer members the opportunity to use ZipDrug, which offers free access to high performing pharmacies that provide customized medication services, hand-delivered prescriptions, and increase medication adherence rates. Go to com/zipdrug or call 844-947-3748.
- Patients who take medications for diabetes, cholesterol, and hypertension and enrolled in ZipDrug had a 4 to 10% increase in medication adherence rates.
- Encourage digital solutions: Sydney app can help Empire members manage their medications through:
- Enrollment in ZipDrug
- Home delivery set-up
- Manage auto-refill and renew
- Text message reminders on prescriptions
Want more information regarding all the recommended best practices?
Best practices for medication adherence are reviewed in this brief video.
Resources:
1 World Health Organization. Adherence to long-term therapies: evidence for action. Geneva:
World Health Organization; 2003. http://apps.who.int/medicinedocs/pdf/s4883e/s4883e.pdf.
Accessed Dec.22, 2021.
2 Cutler, Rachelle Louise et al. “Economic impact of medication non-adherence by disease groups: systematic
review.” BMJ open vol. 8,1 e016982. 21 Jan. 2018, doi:10.1136/bmjopen-2017-016982
3 Journal of Managed Care & Specialty Pharmacy 2020 26:12, 1529-1537
4 JAMA.2018;320(23):2461-2473. https://pubmed.ncbi.nlm.nih.gov/30561486/
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Annual wellness visits (AWVs) are an important yet underutilized vehicle for ensuring successful value-based payment (VBP) arrangements. In 2022, there is an opportunity to increase your AWVs and, by extension, the health of your patients and your success in VBPs.
Per the American Academy of Family Practitioners (AAFP), “90 percent of patients who had received an AWV said they did so at the recommendation of their physician.” AWVs are a yearly exam (usually with a physician) to develop or update a personalized prevention plan and assess health status and any social, psychological, and behavioral health risks. An AWV can be a useful tool for improving quality of care, providing proactive care management, facilitating care coordination, and positively impacting up to 20 Medicare Advantage Star measure ratings for health plans.
There is often confusion between an AWV and an annual routine physical (ARP). The ARP is more comprehensive than an AWV. It consists of a physical exam by a physician and includes bloodwork, screenings, and other tests. The AWV involves checking standard measurements such as blood pressure, height, and weight. AWVs are free for Medicare Advantage members and, in many instances, can be conducted remotely via telehealth.
Note: CMS does allow both visit types to occur on the same date/time and providers can submit one claim encompassing each type.
There are many provider benefits for completing an AWV, including:
- Opportunity to develop a complete medical history for members
- Strengthened relationship with member
- Ability to provide proactive care to member
- Increased performance on quality metrics
- An ongoing, sustainable revenue stream for practice
- Vehicle for providers to obtain caregiver demographics
There are also many member benefits for completing an AWV, including:
- No copay
- Strengthened relationship with healthcare providers
- Annual comprehensive preventive evaluation
- Reduced risk of chronic conditions
- Keeps members out of the hospital
- Prevents accidents at home
In the ever-increasing emphasis on value-based care that focuses on shared savings, it is urgent for providers to complete an AWV for each of their assigned members. Doing so keeps members healthy, reduces healthcare costs, and can increase practice revenues.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield's new Select Medicare Advantage plans on the HealthPlus Select Network (effective January 1, 2022) are available in four downstate counties — Bronx, Brooklyn, Queens, and New York. Medicare HealthPlus Select can be identified with a subscriber ID prefix of RXJ. Medicare HealthPlus Select is a custom-tailored set of new plans comprised of a more focused composition of providers and hospitals.
It is important to note that Medicare HealthPlus Select is not the same as the HealthPlus Medicare Advantage/ DSNP network, which rolled out earlier in 2021. Providers in Bronx, Brooklyn, Queens, and/or New York counties interested in joining Medicare HealthPlus Select should contact their Provider Collaboration Manager regarding the application process and eligibility criteria.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In April 2022, Empire BlueCross BlueShield HealthPlus (Empire) will replace its current internal provider demographic management system with a new Strategic Provider System (SPS). This investment in advanced technology will significantly improve provider data accuracy and transparency, enhancing the overall provider experience. New system features will strengthen our ability to match submitted claims for more accurate pricing and processing.
System upgrades special notice
During the first phase of our improvements, Empire will implement system upgrades April 1, 2022 through April 8, 2022. Provider updates submitted during this period will be processed after April 8, 2022. We appreciate your patience as we upgrade our systems.
Next steps: new Provider Data Management coming soon
Beginning in June 2022, the second phase of our improvement initiative will be integration with Availity’s* Provider Data Management (PDM) functionality, which will roll out in phases. This single, easy-to-use portal, will allow providers to view, maintain, update, and attest to the accuracy of provider demographic information for Empire. The Availity portal will enable providers to complete required verifications online via a simplified quick verification procedure — eliminating the need to fax, email, or use separate online forms. This service will replace the way you currently send Empire your demographic updates.
Get ready for the change today
If your organization is not already registered on the Availity Portal, we strongly encourage you to get started right away. Your organization’s designated administrator can go to https://www.availity.com to register and find other helpful information about using Availity. Availity is Empire’s secure provider portal platform where providers can enjoy the convenience of digital transactions, including prior authorization submissions, claims submission and benefit and eligibility look-up.
For questions about Availity, call 800-AVAILITY (800-282-4548).
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. To support the health of our members, Empire BlueCross BlueShield HealthPlus (Empire) is sending urinary tract infection (UTI) toolkits to select members who were seen in the ER for a UTI.
This useful kit contains:
- A water bottle to help your patient stay
- UTI test strips with instructions on use if having These are test strips that are also available over the counter.
- Basic instructions on how to use the toolkit and reasons to seek
Empire members may reach out to you when they receive their toolkit. If you have any questions, please contact Provider Services at 800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Consumer Assessment of Healthcare Providers and Systems (CAHPS ®) is an annual standardized survey conducted between February and May to assess consumers’ experience with their providers and health plan. A random sample of your adult or child patients may receive the survey.
More than half of the questions used for scoring are directly impacted by providers. These questions are:
- When you needed care right way, how often did you get care as soon as you needed?
- How often did you get an appointment for a check-up or routine care as soon as you needed?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed?
- How often did your personal doctor seem informed and up-to-date about the care you got from other doctors or other health providers?
- How would you rate your personal doctor?
- How would you rate the specialist you see most often?
- How would you rate all your healthcare in the last six months?
Interested in how you can improve CAHPS performance?
Empire BlueCross BlueShield HealthPlus offers an online course for providers and office staff designed to learn how to improve communication skills, build patient trust and commitment, and expand your knowledge of the CAHPS survey. The Improving the Patient Experience course is available at no cost and is eligible for one continuing medical education (CME) credit by the American Academy of Family Physicians. It can be accessed at: https://www.mydiversepatients.com/le-ptexp.html.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. To ensure the cultural competence of our provider network, all Empire BlueCross BlueShield HealthPlus (Empire) contracted/participating providers must certify, on an annual basis, completion of the state-approved cultural competence training curriculum, as required for all participating provider staff who have regular and substantial contact with our members. With this training, participating providers will be positioned to offer more effective care delivery to our members and decrease health disparities.
The New York State Department of Health has approved the cultural competence training offered by the United States Department of Health and Human Services, Office of Minority Health education program, Think Cultural Health. The training is online and can be accessed at https://hclsig.thinkculturalhealth.hhs.gov.
Upon completion, all contracted/participating providers are required to share certification with Empire by the end of the calendar year. Upon training completion, please sign the attached attestation and return to Empire via email at: NYculturalcompetency@empireblue.com.
Provider groups can certify at the group level with one attestation form submitted for all providers in their practice; however, all provider names and national provider identifier (NPI) numbers are required to be listed on the attestation form or have a roster attached.
If you have any questions regarding this requirement, please contact OMCmail@health.ny.gov.
|