Each year, Empire performs a review of a sample of our members’ medical records as part of the HEDIS^® quality study. HEDIS is part of a nationally recognized quality improvement initiative and is used by Centers for Medicare and Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and several states to monitor the performance of managed care organizations.

For 2022, Empire will begin requesting medical records in January 2023. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are a routine part of healthcare operations.

Ways to submit your records:

• Remote electronic medical records (EMR) access service: As we published in the Provider Newsletter, we now offer EMR access to providers to submit member medical record information to Empire. If you are interested in more information, please contact us at Centralized_EMR_Team@empireblue.com.
• Upload: Medical records can be uploaded to the Empire secure website using the instructions in the request document.
• Fax: Medical records can be faxed to Empire using the instructions in the request document.
• U.S. Postal Service: Medical records can be mailed to Empire using the instructions in the request document.
• Onsite: Medical records can be pulled by an Empire representative at your office where medical records are located.
• Secure File Transfer Protocol (SFTP): Medical records can be uploaded via secure website set up by Empire.

HEDIS review is time sensitive, so please submit the requested medical records within the time frame indicated in the initial HEDIS request document.

We appreciate the care you provide our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

In conjunction with National Colorectal Cancer Awareness Month, Empire BlueCross BlueShield (Empire) would like to remind healthcare professionals to raise awareness to their patients about colorectal cancer screenings.

Encourage your patients to make time for regular colorectal cancer screenings. It’s one of the most valuable ways they can protect their health and peace of mind. Colorectal cancer is the third most common type of cancer among adults, but it often doesn’t show any symptoms, especially at first.

The good news is that the survival rate for colorectal cancer is about 90% when it’s caught early, before it’s had the chance to spread. Regular screenings are the number one way to detect it, but many adults who need screenings don’t get them. Making these important tests a priority is about your patients staying healthy and strong for the ones they love.

The American Cancer Society[1] recommends that most adults have regular colorectal cancer screenings from age 45 to age 75. Talk to your patients about when and how often they should be tested and what kind of screening is right for them.

You and your Empire patients have access to high-quality, low-cost colorectal cancer screening fecal immunochemical test (FIT) kits by Labcorp and Quest Diagnostics. If you have specific questions, contact the labs directly:

• Labcorp: FIT test, 888-LABCORP (888-522-2677) or labcorp.com/cancer/colorectal/providers
• Quest Diagnostics: InSure ONE^TM kit, 866-MY-QUEST (866-697-8378) or https://clinical.QuestDiagnostics.com/QuestInSureONE

To find Labcorp, Quest Diagnostics and other participating labs in your patient’s plan network, select Find Care from the Provider Resources menu at https://www.empireblue.com/provider.

[1] Colorectal Cancer Guideline | How Often to Have Screening Tests

This communication applies to Commercial and Medicare Advantage plans from Empire BlueCross BlueShield (Empire).

Effective for dates of service on and after June 1, 2023, the following code updates will apply to the Carelon Medical Benefits Management, Inc. Radiology Clinical Appropriateness Guidelines.

Advanced imaging of the abdomen and pelvis

Oncologic imaging

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon in one of several ways:

• Access the 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 the the Availity* website at availity.com.

If you have questions related to guidelines, please email MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

In March 2020, the parent company of Empire completed its acquisition of Carelon Behavioral Health, Inc (formerly Beacon Health Options, Inc.*). As part of Carelon’s integration, the current Empire behavioral health provider network is being merged into the Carelon provider network. After the provider networks merge, Empire will contract with Carelon to access behavioral health providers in Empire’s service areas. As a result of the integration, impacted behavioral health providers will receive a formal notification in the mail indicating that Empire is assigning their provider agreement in whole to Carelon.

There will not be any changes to rates, clinical, or claims processes with Empire. When serving as a participating provider, you will continue to be eligible to provide healthcare services to Empire members who have Commercial, Medicare Advantage, and Medicaid plans, as applicable to your provider agreement(s) with Empire.

To assist with inquiries pertaining to the integration and assignment of provider agreements to Carelon, we will be hosting two webinars on April 13, 2023, and April 20, 2023. Please register using the links below:

• April 13 at 10 a.m. registration link
• April 20 at 3 p.m. registration link

At a later date, impacted behavioral health providers will receive a subsequent communication from Carelon notifying you of the terms and conditions applicable to your participation in the Carelon network.

If you have questions in the interim, please contact your network representative or email us at Empire-Beacon-Inquiries@empireblue.com.

New ID cards issued for our members effective January 1, 2023

Members and their dependents enrolled in the Screen Actors Guild – American Federation of Television and Radio Artists (SAG-AFTRA) Health Plan had a group number change effective January 1, 2023. In the past, enrollees received their health insurance ID cards directly from SAG-AFTRA Health Plan.  

ID cards

Empire BlueCross BlueShield (Empire) issued new ID cards with the new group number L05927 to all Empire members enrolled in the SAG-AFTRA Health Plan. New ID cards were provided digitally or mailed to all affected members. These ID cards carry the nationally recognized Empire logo. 

It is important to note that any services requiring prior authorization, or any service being rendered on or after January 1, 2023, should be submitted under the new group number (L05927).  We suggest that you update your records with the new group number change. 

Tips to help ensure accurate claims processing and prompt payments  

When Empire members arrive at the office or facility, ask to see their current member identification card at each visit. Many Empire members no longer receive a paper card, so they will present their digital card on their mobile device. Asking this will help:

• Identify the member’s product.
• Obtain health plan contact information.
• Speed claims processing.

Note: Claims providers submit with an incorrect ID number may be unable to be processed and may be returned for correction and resubmission with the correct ID.

Use Availity to verify eligibility and benefits

Through our secure website Availity.com,* you can easily get answers to your questions about claim status, eligibility, and benefits. You can also retrieve electronic remittances, make provider demographic changes, and complete your prior authorization inquiries. 

If you are not an Availity user, visit www.availity.com to register today. It’s safe, secure, and easy to use. 

Contact us

To contact our Provider Service team, please call the Provider Service toll-free number located on the back of the member's new ID card.

Register today for the Advancing Mental Health Equity for Youth & Young Adults forum hosted by Anthem and Motivo* for Anthem providers on March 15, 2023. 

Anthem is committed to making healthcare simpler and reducing health disparities for youth and young adults. We believe that advancing health equity for young people is critical to not only improving their experience, but also ensuring the mental health system is a safe and trusted resource. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem as we discuss the intersection of mental health, race, sexual orientation, gender identity, disability, and supporting youth and young adults on their mental health journey.

Each quarterly forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase diversity equity and inclusion in healthcare.

Wednesday, March 15, 2023

4 to 5:30 p.m. ET 

Please register for this event by visiting this link.

The Controlling High Blood Pressure (CBP) HEDIS^® measure can be challenging as it not only requires proof of a blood pressure (BP) reading, but also that the patient’s blood pressure is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 140/90 mmHG. As we start a new year, it’s important that we have record of your patients’ blood pressure readings and that you continue to monitor patients with elevated readings.

Tips when scheduling members to close CBP care gaps:

• When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
• If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time as well as a reminder to arrive early to avoid a sense of rushing.

Tips for lower BP readings during the appointment:

• Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their blood pressure at both the start and end of the appointment and document the lower reading.
• Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.

Getting credit for adequately controlled blood pressure readings:

• Submit readings via Category II CPT^® codes on claims.
  

  Description	Code
  Diastolic BP	CAT II: 3078F-3080F LOINC: 8462-4
  Diastolic 80 to 89	CAT II: 3079F
  Diastolic greater than/equal to 90	CAT II: 3080F
  Diastolic less than 80	CAT II: 3078F
  Systolic BP	CAT II: 3074F, 3075F, 3077F LOINC: 8480-6
  Systolic greater than/equal to 140	CAT II: 3077F
  Systolic less than 140	CAT II: 3074F, 3075F

• Ensure readings are carefully and appropriately documented within your electronic medical record system.
• If you have questions on how to submit readings, speak to your care or practice consultant.
• Also, be sure to adequately code patients who meet the exclusion criteria:
  • Exclusions:
    • Palliative care
    • Enrolled in hospice
    • Frailty and/or advanced illness
    • Living in long-term care
  • Optional exclusions:
    • Dialysis (ESRD), kidney transplant, nephrectomy
    • Female members with a diagnosis of pregnancy
    • Non-acute inpatient admissions

The provider payment option, Pay Doctor Bill, offered to consumers via InstaMed,* will be terminated effective March 31, 2023. Empire contracted with InstaMed to deliver options for consumers to view their claims and pay their out-of-pocket responsibility to doctors from the Sydney Health mobile app or from https://www.anthem.com/provider. This is not related to the payment of health insurance premiums.

Even though this option will no longer be available, consumers still have other ways of paying doctors:

• Through a Health Savings Account (HSA) or Flexible Spending Account (FSA) if they have this type of account
• Through their bank’s bill pay feature on a mobile app or website
• Directly through doctor’s secure payment website or at the doctor’s office with a debit or credit card

A month prior to the termination of Pay Doctor Bill from the Sydney Health mobile app and the Empire website, we will notify consumers within these applications.

Material Adverse Change (MAC)

Beginning with dates of service on or after April 1, 2023, Empire BlueCross BlueShield HealthPlus will update the Modifiers 25 and 57 policy to not allow reimbursement for CPT code 99211 when appended with Modifier 25 except for vaccine administration.

Based on the descriptions of both Modifier 25 and CPT^® 99211, the Evaluation and Management must be separately identifiable, and CPT 99211 is not a separately identifiable service.

In addition, the policy titled Modifiers 25 and 57: Evaluation and Management with Global Procedures will be renamed to Modifiers 25 and 57.

For additional information, please review the Modifiers 25 and 57 reimbursement policy at https://providerpublic.empireblue.com.

• Clinical Criteria updates
• Prior authorization updates for medications billed under the medical benefit (Carvykti)
• Updates to Carelon Medical Benefits Management, Inc. Cardiac Clinical Appropriateness Guidelines

The Modifier Usage policy is aligning with Medicare modifier requirements by adding the following to our Related Coding section:

• Modifier CO — Outpatient occupational therapy assistant services
• Modifier CQ — Outpatient physical therapy assistant services

Additionally, Modifier FB (Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples) was expanded to facility providers.

For additional information, please review the Modifier Usage reimbursement policy at https://www.empireblue.com/medicareprovider.

Empire BlueCross BlueShield is actively seeking to promote CMS’s transition care management (TCM) program for its Medicare members.

The goal is to ensure comprehensive physician follow-up and management of patients within seven and/or 14 days of discharge from hospital, skilled nursing facility (SNF), inpatient rehabilitation hospital (IRF), or long-term acute care hospitals (LTAC). And thus, to minimize clinical relapses, that often result in acute hospital readmissions, within 30-days of discharge.

CPT^® codes for these visits are:

• 99496 (post-discharge comprehensive follow-up within seven days): pays between $250 to $350, depending on region, and;
• 99495 (post-discharge follow-up within 14 days): pays between $190 to $260, depending on region.

The primary intent for these visits is close post-discharge patient follow up with comprehensive physician/provider management of ongoing chronic comorbidities. So, visits should include:

• Review of the discharge information
• Medication reconciliation
• Treatment of acute exacerbations and/or fluctuations in the physician office as appropriate
• Active management of and attention to chronic renal, lung, cardiac, skeletal, social, caregiver, etc. conditions, and providers should:
  • Review the need for pending diagnostics, and/or follow up of said diagnostics.
  • Interact with other healthcare professionals who may assume care of any system-specific problems.
  • Educate the patient, family, and caregiver.
  • Establish referrals, arrange needed community resources, address/assist/advise the member/family with relevant caregiver needs.
  • Help schedule required community providers and services follow-up .
  • Comprehensively and holistically manage common chronic/acute medical conditions seen after hospital discharge, such as (but not limited to): Heart failure, COPD, DM, AFIB, DVT, cellulitis, pneumonia, dehydration, AMS, encephalopathy, AKI, polypharmacy/medication reconciliation, and even custodial/social needs impacting/resulting in admission(s).

CMS encourages TCM for Medicare members. CMS has detailed fact sheets explaining the program, and billing, see resources below:

• https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf
• https://edit.cms.gov/files/document/billing-faqs-transitional-care-management-2016.pdf

Appendix

CPT 99496 coding requirements:

1. Attestation that the initial communication between patient/practitioner began within two business days of discharge:
   1. Geared to patients with conditions requiring medium or high-level decision-making
   2. Direct contact: telephone/electronic
2. Face-to-face visit within seven days of DC. Cannot be virtual
3. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
4. Includes DC from hospitals, SNFs, IRFs, and LTACs
5. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living

CPT 99495 coding requirements:

1. Attestation that the initial communication between patient/practitioner began within two business days of DC:
   1. Geared to patients with conditions requiring at least moderate complexity decision-making
   2. Direct contact: telephone/electronic
2. Face-to-face visit within 14 days of discharge. Cannot be virtual
3. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
4. Includes DC from hospitals, SNFs, IRFs, and LTACs
5. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living

The Controlling High Blood Pressure (CBP) HEDIS^® measure can be challenging as it not only requires proof of a blood pressure (BP) reading, but also that the patient’s blood pressure is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 140/90 mmHG. As we start a new year, it’s important that we have record of your patients’ blood pressure readings and that you continue to monitor patients with elevated readings.

Tips when scheduling members to close CBP care gaps:

• When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
• If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time as well as a reminder to arrive early to avoid a sense of rushing.

Tips for lower BP readings during the appointment:

• Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their blood pressure at both the start and end of the appointment and document the lower reading.
• Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.

Getting credit for adequately controlled blood pressure readings:

• Submit readings via Category II CPT^® codes on claims.
  

  Description	Code
  Diastolic BP	CAT II: 3078F-3080F LOINC: 8462-4
  Diastolic 80 to 89	CAT II: 3079F
  Diastolic greater than/equal to 90	CAT II: 3080F
  Diastolic less than 80	CAT II: 3078F
  Systolic BP	CAT II: 3074F, 3075F, 3077F LOINC: 8480-6
  Systolic greater than/equal to 140	CAT II: 3077F
  Systolic less than 140	CAT II: 3074F, 3075F

• Ensure readings are carefully and appropriately documented within your electronic medical record system.
• If you have questions on how to submit readings, speak to your care or practice consultant.
• Also, be sure to adequately code patients who meet the exclusion criteria:
  • Exclusions:
    • Palliative care
    • Enrolled in hospice
    • Frailty and/or advanced illness
    • Living in long-term care
  • Optional exclusions:
    • Dialysis (ESRD), kidney transplant, nephrectomy
    • Female members with a diagnosis of pregnancy
    • Non-acute inpatient admissions

• Updates to Carelon Medical Benefits Management, Inc. Cardiac Clinical Appropriateness Guidelines
• Carelon Medical Benefits Management, Inc. Genetic Testing Clinical Appropriateness Guidelines CPT code list update
• Clinical Criteria updates
• New specialty pharmacy medical step therapy requirements (Neulasta, Neulasta OnPro, Udenyca)