 Provider News New YorkMay 2020 Empire Provider NewsBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For the most up-to-date information from Empire about COVID-19, please bookmark Provider News Home and check back often. The most recent articles will be displayed in the Provider Spotlight section.
For a repository of all COVID-19 related articles in one location, please reference the COVID-19 Information under Articles by Publication.
 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield’s (“Empire”) Prospective Risk Adjustment program works to improve risk adjustment accuracy and focus on performing appropriate interventions for patients with undocumented Hierarchical Condition Categories (HCC), in order to help you close your patients’ gaps in care. This program involves:
- Member outreach encouraging primary care physicians (PCP) visits
- Provider outreach sharing previously coded and suspected conditions, and encouraging member visits
- PCP alternatives to complete Health Assessments
Due to our partnership, we expect and encourage you to participate in the Risk Adjustment initiatives.
Inovalon Requests
Consistent with 2019, we have again engaged a vendor, Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with the provisions of the Affordable Care Act that require us to assess members’ relative health risk levels. In the coming weeks and months, Inovalon will begin sending letters to providers as part of a new risk adjustment cycle, asking for your help with completing Health Assessments for some of our members.
If you worked with Inovalon in 2019, many thanks for your help. This year will bring a new round of assessments because chronic conditions must be assessed and coded each and every year. As always, if you have questions about the requests you receive, you can reach Inovalon directly at 1-877-448-8125.
Prospective Program ask of Providers:
Empire network providers – usually PCPs – receive letters from Inovalon, requesting that they:
- Schedule a comprehensive visit with patients identified by Inovalon to confirm or deny if previously coded or suspected diagnoses exists, and;
- Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).
Incentives for properly submitted Health Assessments (these incentives are in addition to the office visit reimbursement):
- $150 for each Health Assessment properly submitted electronically
- $50 for each Health Assessment properly submitted via fax
Submit electronically via Inovalon’s ePASS tool:
- Inovalon ePASS® Training Webinars
- Every Wednesday - 3:00 - 4:00 PM EST
- Join an ePASS webinar:
Alternative Engagement
ePASS® is our preferred method for submission. However to improve engagement and collaborate with our providers who are not submitting via ePASS®, we have identified other tools which may be helpful. If in 2019 your practice utilized some of these alternative options for prospective member outreach, we thank you for continuing on these alternative forms of program participation into 2020.
For those providers not familiar with our alternative options, they are listed below. Any questions your office has on these can be directed to either your local Provider Representative, or the Empire CRA Network Education Representative listed below.
- EPHC Providers using PCMS - Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool to schedule members for comprehensive visits. PCMS does have a link to take you directly to the Inovalon ePASS® tool where completed Health Assessments will result in a $150 incentive payment per submitted Health Assessment.
- List of Members to be scheduled - Empire CRA provides member/patient reports for providers to schedule members for comprehensive visits. Providers use normal gap closure through claims submission. No Health Assessment needed. Not eligible for additional incentive.
- EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Inovalon at 1-866-682-6680 with a coversheet indicating "see attached Empire Progress Note,” which is eligible for a $50 incentive payment.
- Providers Existing Patient Assessment Form (PAF) - Utilize providers existing EMR system and applicable PAF. Must be submitted to Inovalon at 1-866-682-6680 with coversheet indicating, "see attached Empire Progress Note,“ which is eligible for a $50 incentive payment.
Please contact our Commercial Risk Adjustment Network Education Representative, Alicia.Estrada@anthem.com if you have any questions:
Thank you for your continued efforts with our CRA Program.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Diabetes is a complex chronic illness requiring ongoing patient monitoring. NCQA includes diabetes in its HEDIS® measures on which providers are rated annually. Since diabetes HbA1c testing is a key measure to assess for future medical conditions related to complications of undiagnosed diabetes, the National Committee for Quality Assurance (NCQA) requires health plans to review claims for diabetes in patient health records. The findings contribute to health plan stars ratings for Commercial and Medicare plans and the Quality Rating System (QRS) measurement for Marketplace plans. A systematic sample of patient records is pulled annually as part of the HEDIS® medical record review to assess for documentation.
Which HEDIS measures are Diabetes Measures?
The diabetes measures focus on members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following assessments:
- Hemoglobin A1c (HbA1c) testing
- HbA1c poor control (>9.0%)
- HbA1c control (<8.0%)
- Dilated Retinal exam
- Medical attention for nephropathy
The American College of Physicians’ guidelines for people with type 2 diabetes recommend the desired A1c blood sugar control levels remain between 7 to 8 percent.1
In order to meet the HEDIS measure “HbA1c control <8”, you must document the date the test was performed and the corresponding result. For this reason, report one of the four Category II codes and use the date of service as the date of the test, not the date of the reporting of the Category II code.
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To report most recent hemoglobin A1c level
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Use
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HbA1c level less than 7.0%
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3044F
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HbA1c level greater than or equal to 7.0% and less than 8.0%
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3051F
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HbA1c level greater than or equal to 8.0% and less than or equal to 9.0%
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3052F
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HbA1c level greater than 9.0%
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3046F
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HbA1c level ≤9.0%
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3044F, 3051F, 3052F2
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NOTE: Multiple dates of service may be associated with a single lab test (e.g., a collection date, a reported date and a claim date). For a laboratory test CPT II code to count toward HEDIS, the Category II date of service and the test result date must be no more than seven days apart.
Continued management and diverse pathways to care are essential in controlling blood glucose and reducing the risk of complications. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value Based Services, and other pay-for-performance models.3
Sources include:
- Diabetes Prevalence: 2015 state diagnosed diabetes prevalence, cdc.gov/diabetes/data; 2012 state undiagnosed diabetes prevalence, Dall et al., ”The Economic Burden of Elevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.
- Diabetes Incidence: 2015 state diabetes incidence rates, cdc.gov/diabetes/data
- Cost: American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”, Diabetes Care, May 2018.
- Research expenditures: 2017 NIDDK funding, projectreporter.nih.gov; 2017 CDC diabetes funding, www.cdc.gov/fundingprofiles
1 https://www.medicalnewstoday.com/articles/321123#An-A1C-of-7-to-8-percent-is-recommended
2 https://www.ama-assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-clinical-topics.pdf
3 https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. These updates list the new and/or revised Empire BlueCross BlueShield (“Empire”) medical policies, clinical guidelines and reimbursement policies*. The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.
Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire. Please include this update with your Provider Manual for future reference.
Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Empire’s medical policies and clinical guidelines can be found at empireblue.com.
*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.
Medical Policy Updates
Revised Medical Policies Effective 02-27-2020
(The following policies were revised to expand medical necessity indications or criteria.)
- GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
- SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Revised Medical Policy Effective 04-01-2020
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing
Revised Medical Policies Effective 04-15-2020
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
- DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting
- DME.00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
- DME.00032 - Automated External Defibrillators for Home Use
- GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00007 - Cardiac Ion Channel Genetic Testing
- GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
- GENE.00017 - Genetic Testing for Diagnosis of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
- GENE.00038 - Genetic Testing for Statin-Induced Myopathy
- GENE.00050 - Gene Expression Profiling for Coronary Artery Disease
- LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00011 - Analysis of Proteomic Patterns
- LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
- LAB.00025 - Topographic Genotyping
- MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
- MED.00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
- MED.00024 - Adoptive Immunotherapy and Cellular Therapy
- MED.00053 - Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
- MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00059 - Idiopathic Environmental Illness (IEI)
- MED.00077 - In-Vivo Analysis of Gastrointestinal Lesions
- MED.00087 - Imaging Techniques for Screening and Identification of Cervical Cancer
- MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
- MED.00102 - Ultrafiltration in Decompensated Heart Failure
- MED.00104 - Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
- MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00111 - Intracardiac Ischemia Monitoring
- MED.00112 - Autonomic Testing
- MED.00118 - Continuous Monitoring of Intraocular Pressure
- MED.00120 -Gene Therapy for Ocular Conditions
- MED.00125 - Biofeedback and Neurofeedback
- OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
- RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification
- RAD.00044 - Magnetic Resonance Neurography
- RAD.00052 - Positional MRI
- RAD.00059 - Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
- SURG.00022 - Lung Volume Reduction Surgery
- SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
- SURG.00053 - Unicondylar Interpositional Spacer
- SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
- SURG.00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses
- SURG.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
- SURG.00070 - Photocoagulation of Macular Drusen
- SURG.00072 - Lysis of Epidural Adhesions
- SURG.00075 - Intervertebral Stabilization Devices
- SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation
- SURG.00107 - Prostate Saturation Biopsy
- SURG.00113 - Artificial Retinal Devices
- SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
- SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer
- SURG.00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
- SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
- SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
- SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
- SURG.00151 - Balloon Dilation of Eustachian Tubes
- SURG.00152 - Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
- TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation
- TRANS.00013 - Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
- TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
- TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Revised Medical Policies Effective 04-01-2020
(The following policies were updated with CPT/HCPCS procedure code updates.)
- GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
Archived Medical Policy Effective 04-15-2020
(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)
- SURG.00016 - Stereotactic Radiofrequency Pallidotomy [Note: Content transferred to CG-SURG-108 Stereotactic Radiofrequency Pallidotomy.]
Archived Medical Policies Effective 04-15-2020
(The following policies have been archived.)
- MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
- RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
- THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
Archived Medical Policy Effective 04-18-2020
(The following policy has been archived.)
- MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
Revised Medical Policy Effective 04-18-2020
(The following policy was updated with CPT/HCPCS procedure code updates.)
- SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
Revised Medical Policy Effective 04-18-2020
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- SURG.00127 - Sacroiliac Joint Fusion
Archived Medical Policy Effective 05-17-2020
(The following policy has been archived and has been replaced by AIM guidelines.)
- SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
Archived Medical Policy Effective 07-01-2020
(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) [Note: Content transferred to CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH).]
Clinical Guideline Updates
Revised Clinical Guidelines Effective 02-27-2020
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-REHAB-04 - Rehabilitative and Habilitative Services: Medicine/Physical Therapy
- CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
- CG-REHAB-06 - Rehabilitative and Habilitative Services: Speech-Language Pathology
Revised Clinical Guidelines Effective 04-01-2020
(The following adopted clinical guidelines were updated with CPT/HCPCS procedure code updates.)
- CG-MED-23 – Home Health
- CG-REHAB-04 - Rehabilitative and Habilitative Services: Medicine/Physical Therapy
- CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
- CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
- CG-SURG-27 - Gender Reassignment Surgery
Revised Clinical Guidelines Effective 04-15-2020
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-DME-06 - Pneumatic Compression Devices for Lymphedema
- CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
- CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
- CG-GENE-07 - BCR-ABL Mutation Analysis
- CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
- CG-GENE-09 - Genetic Testing for CHARGE Syndrome
- CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
- CG-MED-55 - Level of Care: Advanced Radiologic Imaging
- CG-MED-69 - Inhaled Nitric Oxide
- CG-SURG-09 - Temporomandibular Disorders
- CG-SURG-74 - Total Ankle Replacement
- CG-SURG-97 - Cardioverter Defibrillators
- CG-SURG-99 - Panniculectomy and Abdominoplasty
- CG-TRANS-02 - Kidney Transplantation
Recategorized Clinical Guideline Effective 04-15-2020
(The following adopted guideline was reviewed and had no significant changes to the policy position or criteria.)
- CG-MED-88 Preimplantation Genetic Diagnosis Testing [NOTE: This guideline has been renumbered, formerly CG-GENE-06.]
Archived Clinical Guideline Effective 04-15-2020
(The following adopted clinical guideline has been archived.)
- CG-MED-82 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
Archived Clinical Guideline Number Effective 04-15-2020
(The following guideline number has been archived and its content has been transferred to a new Clinical UM Guideline number.)
- CG-GENE-06 - Preimplantation Genetic Diagnosis Testing [Note: Content transferred to CG-MED-88 Preimplantation Genetic Diagnosis Testing.]
Revised Clinical Guideline Effective 05-01-2020
(The following adopted clinical guideline was updated with CPT/HCPCS procedure code updates.)
- CG-GENE-13 - Genetic Testing for Inherited Diseases
Adopted Clinical Guideline Effective 07-01-2020
(The following guideline was previously a medical policy and has been adopted and has no significant changes.)
- CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) [Note: Content moved from SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH).]
Corrections to the Policy Update section of the April 2020 Newsletter
In the April 2020 provider newsletter we communicated that a coding update would be made in the claims system effective July 18, 2020 which may result in a not medically necessary determination for CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone. This change will not be put in place on July 18, 2020, and we will communicate, in the future, when the coding update will be applied.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield’s (“Empire”) 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 February 21, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised Clinical Criteria effective March 3, 2020
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0140 Zulresso (brexanolone)
Archived Clinical Criteria Effective March 23, 2020
The following clinical criteria document has been archived and its content has been transferred to an existing Pharmacy and Therapeutics (P&T) clinical criteria document.
- ING-CC-0138 Asparlas (calaspargase pegol-mknl) [Note: Content moved to ING-CC-0096 Asparagine Specific Enzymes]
Revised Clinical Criteria effective March 23, 2020
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0090 Ixempra (ixabepilone)
- ING-CC-0091 Lartruvo (olaratumab)
- ING-CC-0094 Alimta (pemetrexed disodium)
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0121 Gazyva (obinutuzumab)
- ING-CC-0123 Cyramza (ramucirumab)
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0130 Imfinzi (durvalumab)
- ING-CC-0131 Besponsa (inotuzumab ozogamicin)
Revised Clinical Criteria effective March 23, 2020
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0044 Exondys 51 (eteplirsen)
- ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
- ING-CC-0075 Rituximab Agents for Non-Oncology Indications
- ING-CC-0085 Actimmune (interferon gamma-1B)
- ING-CC-0086 Spravato (esketamine) Nasal Spray
- ING-CC-0089 Mozobil (plerixafor)
- ING-CC-0096 Asparagine Specific Enzymes [Note: Content for Asparlas (calaspargase pegol-mknl) moved from ING-CC-0138]
- ING-CC-0103 Faslodex (fulvestrant)
- ING-CC-0108 Halaven (eribulin)
- ING-CC-0110 Perjeta (pertuzumab)
- ING-CC-0113 Sylvant (siltuximab)
- ING-CC-0115 Kadcyla (ado-trastuzumab)
- ING-CC-0117 Empliciti (elotuzumab)
- ING-CC-0120 Kyprolis (carfilzomib)
- ING-CC-0122 Arzerra (ofatumumab)
- ING-CC-0126 Blincyto (blinatumomab)
- ING-CC-0129 Bavencio (avelumab) injection
- ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
- ING-CC-0152 Vyondys 53 (golodirsen)
Revised Clinical Criteria effective May 1, 2020
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
Revised Clinical Criteria effective July 1, 2020
The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0078 Orencia (abatacept)
New Clinical Criteria effective August 1, 2020
The following clinical criteria are new.
- ING-CC-0155 Ethyol (amifostine)
- ING-CC-0156 Reblozyl (luspatercept)
- ING-CC-0157 Padcev (enfortumab vedotin)
- ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
- ING-CC-0159 Scenesse (afamelanotide)
- ING-CC-0160 Vyepti (eptinezumab-jjmr)
Revised Clinical Criteria effective August 1, 2020
The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0015 Infertility and HCG Agents
- ING-CC-0033 Xolair (omalizumab)
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0043 Monoclonal Antibodies to Interleukin-5
- ING-CC-0049 Radicava (edaravone)
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0088 Elzonris (tagraxofusp-erzs)
- ING-CC-0094 Alimta (pemetrexed disodium)
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0109 Zaltrap (ziv-aflibercept)
- ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
- ING-CC-0118 Radioimmunotherapy: Zevalin; azedra; Lutathera
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0123 Cyramza (ramucirumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0135 Melanoma Vaccines
Coding Updates
As a result of coding updates in the claims system, the claim system edits for the clinical criteria listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.
Effective August 15, 2020, we will be implementing coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.
- ING-CC-0027 Denusumab Agents
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Advanced Imaging of the Chest and AIM Oncologic Imaging Clinical Appropriateness Guidelines.
Advanced Imaging of the Chest updates by section:
Tumor or Neoplasm
- Allowed follow up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow up recommendations for nodules of the same size seen on complete thoracic CT
- Added new criteria for which follow up is indicated for mediastinal and hilar lymphadenopathy
- Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry
Parenchymal Lung Disease – not otherwise specified
- Removed as it is covered elsewhere in the document (parenchymal disease in Occupational lung diseases and pleural disease in Other thoracic mass lesions)
Interstitial lung disease (ILD), non occupational including idiopathic pulmonary fibrosis (IPF)
- Defined criteria warranting advanced imaging for both diagnosis and management
Occupational lung disease (Adult only)
- Moved parenchymal component of asbestosis into this indication
- Added Berylliosis
Chest Wall and Diaphragmatic Conditions
- Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved
- Limited evaluation of clinically suspected rupture to patients with silicone implants
Oncologic Imaging updates by section:
MRI breast
- New indication for BIA-ALCL
- New indication for pathologic nipple discharge
- Further define the population of patients most likely to benefit from preoperative MRI
Breast cancer screening
- Added new high risk genetic mutations appropriate for annual breast MRI screening
Lung cancer screening
- Added asbestos-related lung disease as a risk factor
As a reminder, ordering and servicing providers may submit prior authorization requests in AIM in one of several ways:
- 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 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.
For 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 here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guideline.
Sleep Disorder Management updates by section:
Bi-Level Positive Airway Pressure Devices
- Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and aligns with Medicare requirements for use of BPAP.
Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing
Code Changes: None
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- 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 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.
For 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 here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Musculoskeletal Program: Interventional Pain Management Clinical Appropriateness Guideline.
Musculoskeletal Program: Interventional Pain Management Guideline updates by section:
General Requirements – Conservative Management
- Addition of physical therapy or home therapy requirement and one complementary modality based on preponderance of benefit over harm to conservative care
- Align with approach to conservative management defined in spine and joint surgery guidelines
Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
- Addition of statement about adherence to ESI procedural best practices established by FDA Safe Use Initiative. Recommendations are intended for provider education and will not be used for adjudication.
- Clarification of intent around requirement for advanced imaging for repeat injections
Paravertebral Facet Injection/Nerve Block/Neurolysis
- Remove indication for 4 unilateral medial branch blocks per session based on panel consensus
Paravertebral Facet Injection/Nerve Block/Neurolysis continued
- Procedural clarification restricting use of corticosteroids for diagnostic MBB based on panel consensus
- Limit use of intra-articular steroid injection to mechanical disruption of a facet synovial cyst
- Remove indication for intra-articular steroid injections based on new evidence for lack of efficacy
- Increase duration of initial RFN efficacy needed to avoid a MBB to 6 months based on panel consensus
- Clarification that MBB or RFN is not medically necessary after spinal fusion
Spinal Cord and Nerve Root Stimulators
- Clarify inclusion of different stimulation methods for spinal cord stimulation
- Add new indication for dorsal root ganglion stimulation
- Clarify exclusions for spinal cord and dorsal root ganglion stimulation
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- 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 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.
For 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 here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As recently communicated in the February 2020 edition of Empire BlueCross BlueShield’s (“Empire”) Provider News, effective for dates of service on and after May 17, 2020, updates will apply to the AIM Musculoskeletal Program: Joint Surgery Clinical Appropriateness Guidelines. These updates relate to the criteria in the following sections:
- Hip arthroplasty
- Knee arthroscopy and open procedures
- Shoulder arthroplasty including the removal of the indication for subacromial impingement with rotator cuff tear
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- 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 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.
For 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 here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a reminder, we are continuing to update our claim editing software for outpatient claims on a monthly basis throughout 2020. These updates will:
- reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
- include updates to National Correct Coding Initiative (NCCI) edits
- include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
- include assistant surgeon eligibility in accordance with the policy
- include edits associated with reimbursement policies including, but not limited to, frequency edits, medically unlikely edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
- apply to any provider or provider group (tax identification number) and may apply to both institutional and professional claim types including looking across claim types to determine where conflicts may exist between professional (CMS-1500) claims and institutional (CMS-1450) claims.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective August 1, 2020, Empire will update its Outpatient Surgical Grouper tables for Current Procedure Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS). Enhancements are designed to update the current Outpatient Surgery Grouper levels assigned to these procedure codes. These updates will reinforce the predictability of the fixed rate payment methodology. Additionally, codes that are carved out at an agreed upon fixed rate remain unchanged
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Federal Employee Program® (FEP) at Empire Blue Cross and Blue Shield is committed to delivering exceptional service to our New York customers. In a previous year’s communication (August 2018), we informed our provider community of some administrative changes to provide more consistency and alignment within our business.
This newsletter article information is a friendly reminder of the correct address to be used for Federal Employee (FEP) paper claims and correspondence.
Correct Mailing Address:
Federal Employee Program (FEP) Claims and Correspondence
P.O. Box 105557
Atlanta, GA 30348-5557
The Federal Employee Program (FEP) NO LONGER uses the address below, and mail will discontinue to be forwarded to the correct address above.
PO Box 3876
Church Street Station
New York, New York 10008-3876
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Prior authorization updates
Effective for dates of service on and after August 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the clinical criteria document information please click here.
Empire BlueCross BlueShield’s (“Empire”) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are in italics in the table below.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0156
|
J3490
|
Reblozyl
|
|
ING-CC-0156
|
J3590
|
Reblozyl
|
|
ING-CC-0156
|
C9399
|
Reblozyl
|
|
ING-CC-0157
|
C9399
|
Padcev
|
|
ING-CC-0157
|
J9309
|
Padcev
|
|
ING-CC-0158
|
J3490
|
Enhertu
|
|
ING-CC-0158
|
J3590
|
Enhertu
|
|
ING-CC-0158
|
C9399
|
Enhertu
|
|
ING-CC-0158
|
J9999
|
Enhertu
|
|
ING-CC-0159
|
J3490
|
Scenesse
|
|
ING-CC-0159
|
J3590
|
Scenesse
|
|
ING-CC-0155
|
J0207
|
Ethyol
|
|
ING-CC-0160
|
J3490
|
Vyepti
|
|
ING-CC-0160
|
J3590
|
Vyepti
|
|
*ING-CC-0002
|
J3590
|
Ziextenzo
|
|
*ING-CC-0002
|
C9399
|
Ziextenzo
|
|
ING-CC-0062
|
J3590
|
Avsola
|
|
ING-CC-0062
|
J3590
|
Abrilada
|
|
ING-CC-0062
|
C9399
|
Abrilada
|
|
ING-CC-0065
|
J7192
|
Esperoct
|
* Non-oncology use is managed b Empire’s medical specialty drug review team; oncology use is managed by AIM.
Site of care updates
Effective for dates of service on and after August 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing prior authorization site of care review process.
To access the site of care drug list, please click here.
Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are in italics in the table below.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0082
|
J0222
|
Onpattro
|
|
ING-CC-0043
|
J0517
|
Fasenra
|
|
ING-CC-0049
|
J1301
|
Radicava
|
|
ING-CC-0041
|
J1303
|
Ultomiris
|
|
ING-CC-0003
|
J1599
|
Asceniv
|
|
ING-CC-0047
|
J1746
|
Trogarzo
|
|
ING-CC-0050
|
J3245
|
Ilumya
|
|
ING-CC-0013
|
J3397
|
Mepsevii
|
|
ING-CC-0002
|
Q5110
|
Nivestym
|
|
ING-CC-0002
|
Q5111
|
Udenyca
|
Step therapy updates
Effective for dates of service on and after August 1, 2020, 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. Avsola will be added as a non-preferred agent to clinical criteria ING-CC-0062.
To access the step therapy drug list, please click here.
Prior authorization clinical review of these specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team.
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS Code(s)
|
|
ING-CC-0062
|
Non-preferred
|
Avsola
|
J3590
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (Policy 06-004, effective 08/01/20)
Effective August 1, 2020, Empire BlueCross BlueShield HealthPlus will continue to allow reimbursement for unlisted, unspecified or miscellaneous codes. Unlisted, unspecified or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure or item rendered. Reimbursement is based on review of the unlisted, unspecified or miscellaneous codes on an individual claim basis. Claims submitted with unlisted, unspecified or miscellaneous codes must contain specific information and/or documentation for consideration during review.
For additional information, please review the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Anthem, Inc. completed its acquisition of Beacon Health Options (Beacon), a large behavioral health organization that serves more than 36 million people across the country. Beacon will operate as a wholly owned subsidiary of Anthem. Empire BlueCross BlueShield HealthPlus is a wholly owned subsidiary of Anthem.
Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole-person care solutions in new and meaningful ways to help people live their best lives.
From the standpoint of our customers and providers at this time, it’s business as usual:
- Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
- Providers should continue to use the provider service contact information, websites and online self-service websites as part of their agreement with either Empire BlueCross BlueShield HealthPlus or Beacon.
- There will be no immediate changes to the way Empire BlueCross BlueShield HealthPlus or Beacon manage their respective provider networks, contracts and fee arrangements. Empire BlueCross BlueShield HealthPlus and Beacon provider networks, contracts and fee arrangements will remain separate at this time.
We know our providers continue to expect more of their health care partner, and at Empire BlueCross BlueShield HealthPlus, we aim to deliver more in return.
For more details, please see the press release, and/or additional details will be shared in future communications.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (Policy 06-004, effective 08/01/20)
Effective August 1, 2020, Empire BlueCross BlueShield will continue to allow reimbursement for unlisted, unspecified or miscellaneous codes. Unlisted, unspecified or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure or item rendered.
Reimbursement is based on review of the unlisted, unspecified or miscellaneous codes on an individual claim basis. Claims submitted with unlisted, unspecified or miscellaneous codes must contain specific information and/or documentation for consideration during review.
For additional information, please review the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Background: Empire BlueCross BlueShield wants to make multi-dose packaging available to your patients to help support medication adherence. It’s a simpler, safer way for your patients to manage their medications. Multi-dose packaging is a free service available to members at select network pharmacies.
What is multi-dose packaging?
Multi-dose packaging (MDP) involves organizing prescription and over-the-counter products to provide ease to patients when taking their routine medications. Each MDP dispenser provides patients with a personalized roll of pre-sorted medication packs, labeled with the date and time of the patient's next scheduled dose. MDP helps reduce the stress of determining which medications to take, when to take them and how much of them to take.
Who provides these services?
MDPs can be shipped to the CVS* retail pharmacy of choice or directly to a patient’s home at no additional charge. The MDP Care team is available 24/7 to address patient questions and concerns. The team also coordinates mid-month prescription changes with local CVS pharmacies. CVS MDP is licensed in all states and the District of Columbia.
If CVS isn't the right fit based on geography, PillPack* can provide MDP services for your patients. Packages can include prescription medication, over-the-counter medication and vitamins, and will include a date and time stamp on each packet to help your patients remember to take their medications. Patient copays should be the same; in some cases, it may be cheaper.
How do I refer my patients to MDP providers?
For CVS: Patients can enroll online at https://www.CVS.com/multidose or call 1-800-753-0596. Patients residing in the District of Columbia, Georgia or South Carolina should call 1-844-650-1637 (due to remote practice restrictions). Members may also enroll at their local CVS pharmacy.
For PillPack: Patients interested in PillPack can enroll online at https://www.pillpack.com/blue or via phone by calling 1-866-282-9462.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |