Provider News New YorkMay 2021 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. All associates who make utilization management decisions are required to adhere to the following principles:
- Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
- We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support denials of benefits.
- Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization or create barriers to care and service.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Often, healthcare costs incurred by Empire BlueCross BlueShield (“Empire”) members are a result of recommendations made by their physicians. As an Empire participating physician, you can help reduce your patients’ healthcare costs. Choices, such as where to refer a Member for Negative Pressure Wound Therapy, can have a significant impact on your patients’ ultimate out-of-pocket liability. We are sharing the following information with you for consideration when referring patients for Negative Pressure Wound Therapy.
Our Members, your patients, often participate in health benefit plans that may have coinsurance or deductibles. Your patients may experience significant differences in cost depending on which Negative Pressure Wound Therapy providers the Members are referred to. The following table provides a sample listing of Empire high quality, low cost national Negative Pressure Wound Therapy providers. Referring to these providers will likely lower your patients’ out-of-pocket costs.
Provider
|
Phone Number
|
Apria
|
1-800-780-1228
|
Rotech
|
1-844-592-5068
|
You can find all of Empire’s participating durable medical equipment (DME) Orthotics and Prosthetics providers, at “Find Care” -- <Empire’s doctor finder and transparency tool – at www.empireblue.com.
Empire is committed to seeking ways to reduce healthcare costs, and your referrals to network- participating providers can help make a difference. We appreciate your partnership in considering the financial impact to your patients – our members – especially during these challenging economic times.
If you have questions, please contact your local Network Relations Consultant or call Provider Services.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Digital Online Scheduling Feature Now Available in the Availity Portal
The Appointment Scheduler application in Availity Payer Spaces is an online appointment-scheduling feature that allows providers to manage appointments with patients that may want to schedule appointments directly. Providers can manage patients’ appointment requests and maintain their appointment availability.
Providers can receive new appointment requests from active members, along with important information like the member’s ID number, contact information and any special health information they want the doctor to know. Providers can modify or deactivate their availability at any time. Availity Users with the role of “Office Staff” can set up physicians in the practice to accept online appointment requests.
Enrollment for Appointment Scheduler is easy. To access Appointment Scheduler in the Availity portal: Availity > Payer Spaces > Select Payer Tile > Applications
Appointment Scheduler Features:
- Manage appointment requests and view physician availability
- Configure appointment availability
- Notification of new visit requests on Availity Notification Center and via email
- Members are notified directly via text or email once appointment is confirmed
- Send patient reminders via the Appointment Scheduler application
- Customize office locations and available times, as well as the types of appointments accepted
Visit the Appointment Scheduler application in the Availity portal today.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well. The current health crisis illuminates this quite clearly. It is imperative to offer care that is tailored to the unique needs of patients, and Empire BlueCross BlueShield (“Empire”) is committed to supporting our providers in this effort.
MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:
- Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers to enhance care.
- Real life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.
While there is no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.
Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.
My Diverse Patients
Stronger Together Health Equity Resources
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. After receiving your feedback, we expanded our server to meet your need to upload larger files to our digital attachment tool, through Availity. You can now upload files up to 100 megabytes, eliminating the need to mail or fax.
Use the attachment tool to upload:
- Medical records
- Itemized bills
- Payment dispute
- EOB
- General correspondence
- Consent forms
The digital attachment tool file size expansion is just one example of how Empire is using digital technology to improve the healthcare experience, with a goal to save you valuable time.
Access the attachment tool through www.Availity.com. From the Claims & Payments header, select Attachments – New. For more information about how to setup electronic attachments, use the Getting Started Guide: Select Help & Training>Find Help and then the Attachments topic in Contents. Once logged on you can also access the Getting Started Guide using this link.
For information about setting up for Program Integrity attachments, once logged on to Availity, use this link. You can also access Program Integrity attachment information from the Custom Learning Center: Payer Spaces>Custom Learning Center>Electronic Medical Records.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Our organization is working robustly to establish Empire BlueCross BlueShield (“Empire”) as a digital-first enterprise and to streamline your daily working tasks by using electronic functionalities. In support of the Digital-First Solutions we are excited to publish two Provider Bulletins about submitting medical attachments and itemized bills in partnership with Availity.
The objective of the bulletins is to provide a simple guide for you and your staff with step-by-step navigation instructions, where to find help and training with medical attachments.
The provider bulletins are posted on the Custom Learning Center (CLC) under the Resources tab. Follow these steps to access the helpful documents:
- Availity > Payer Spaces > Select Payer Tile > Applications > Custom Learning Center
- Select Catalog > Resources to locate, view or download the Provider Bulletins
Please encourage your staff who have questions on the process or who are not submitting claim attachments electronically to review these valuable resources for assistance.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. A WISEWOMANTM knows that improving blood pressure is good for the heart
In honor of National High Blood Pressure Education Month, learn more about CDC’s WISEWOMAN program: Well-Integrated Screening and Evaluation for WOMen Across the Nation. The aim of this program is to improve the delivery of heart disease and stroke prevention services for underserved women, aged 40-64 years. The program focuses on cardiovascular disease risk factors, specifically improving high blood pressure1. To learn even more about WISEWOMAN, visit the CDC website.
Resources for your Patients If your patient is one of the tens of millions of American adults who have hypertension, you know encouraging a healthier lifestyle and prescribing the right medications is important to managing the condition. But, if you would like to provide additional information about high blood pressure to your patients, take advantage of the helpful resources available to healthcare professionals through the CDC. The Hypertension Communications Kit provides blood pressure logs, tip sheets, and more. Hypertension Patient Education Handouts include fact sheets, medication information and dozens of useful tools.
Meeting the HEDIS® measure?
Controlling High Blood Pressure (CBP) assesses adults ages 18-85 with a diagnosis of hypertension and whose blood pressure was properly controlled base on the following criteria
- Adults 18-59 years of age whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg
Patient claims should include one systolic reading and one diastolic reading2:
CPT II Code
|
Most recent systolic blood pressure
|
3074F
|
<130 mm Hg
|
3075F
|
130-139 mm Hg
|
3077F
|
≥ 140 mm Hg
|
CPT II Code
|
Most recent diastolic blood pressure
|
3078F
|
<80 mm Hg
|
3079F
|
80-89 mm Hg
|
3080F
|
≥ 90 mm Hg
|
When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.
Additional tips for talking to patients
- Continue to educate patients about the risks of hypertension
- Encourage weight loss, regular exercise, and diet
- Advise patients who are smoking to quit
- Talk about chronic stress and ways to cope with it in a healthy way
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care. Known as the “periodicity schedule,” this screenings and assessments guideline provides a comprehensive schedule for each well-child visit, from infancy.
Schedule for well-child visits
The AAP recommends that children should have a total of eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure. Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures.
Complete coverage for well-child visits Regardless of when visit is received
Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.
HEDIS® measures W30 and WCV
Well-child visits in the first 30 months of life (W30) Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:
- Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
- Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.
Child and adolescent well-care visits Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
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 May 1, 2021, the following update will apply to the AIM Oncologic Imaging Clinical Appropriateness Guideline as recommended by the United States Preventive Service Taskforce Lung Cancer: Screening statement.
- Expanded low-dose CT screening for ages equal to or greater than 50 and less than or equal to 80 AND 20 or greater pack-year history of cigarette smoking.
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. 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.
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.
Clinical guideline updates
New Clinical Guideline Adopted Effective 08-01-2021
(The following guideline will be applied and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-SURG-55 - Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the January 2021 edition of Provider News, we shared information regarding changes to the Frequency Editing Professional Reimbursement Policy. The notice indicated that constant attendance, timed modalities for physical therapy, occupational therapy or speech therapy are limited to 4 Units or 1 hour per date of service for the same member, by the same provider, per therapy type for (97110 – 97124, 97129, 97130, 97140, 97533 – 97542, 97760 – 97763). Upon further review, we have reconsidered our position and have removed this edit for dates of service on or after April 1, 2021.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. To more appropriately align program intention to support member care coordination and to ensure compliance with regulatory requirements surrounding the program, Empire BlueCross BlueShield (“Empire”) is amending the approach for enhanced reimbursement that accompanies selection of ‘on-pathway’ chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program.
Effective July 1, 2021, enhanced reimbursements for medical oncologists selecting on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy authorization process will be adjusted for specific regimens.
Impacted regimens include only select oral and hormonal agents for which a monthly in-office visit may not be required. For these impacted regimens, the optional enhanced reimbursement award, billable using S-codes for treatment planning and care coordination management for cancer, will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353).
This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates.
AIM/Empire will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support.
For a list of the specific regimens that will be impacted by these changes, please see the attachment.
Contact your Empire network representative or your oncology provider engagement liaison for more information.
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 March 15, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.
New Clinical Criteria effective March 31, 2021
The following clinical criteria are new.
- ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
- ING-CC-0192 Cosela (trilaciclib)
Revised Clinical Criteria effective March 31, 2021, 2021
The following clinical criteria was reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)
Revised Clinical Criteria effective April 26, 2021
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0064 Interleukin-1 Inhibitors
- ING-CC-0075 Rituxan (rituximab) for Non-Oncologic Indications
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- ING-CC-0145 Libtayo (cemiplimab-rwlc)
- ING-CC-0151 Yescarta (axicabtagene ciloleucel)
Revised Clinical Criteria effective April 26, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0037 Kanuma (sebelipase alfa)
- ING_CC-0070 Jetrea (ocriplasmin)
- ING-CC-0087 Gamifant (emapalumab-lzsg)
- ING-CC-0160 Vyepti (eptinezumab)
- ING-CC-0182 Agents for Iron Deficiency Anemia
Revised Clinical Criteria effective May 1, 2021
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
Revised Clinical Criteria effective July 1, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0034 Hereditary Angioedema Agents
New Clinical Criteria effective August 1, 2021
The following clinical criteria are new.
- ING-CC-0193 Evkeeza (evinacumab)
- ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
Revised Clinical Criteria effective August 1, 2021
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-0130 Imfinzi (durvalumab)
- ING-CC-0145 Libtayo (cemiplimab-rwlc)
- ING-CC-0159 Scenesse (afamelanotide)
The following Clinical Criteria document was endorsed at the April 8, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.
New Clinical Criteria effective April 13, 2021
The following clinical criteria is new.
- ING-CC-0195 Abecma (idecabtagene vicleucel)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the March 2021 issue of Provider News, we advised we would no longer require prior authorization for the following drugs used to treat ocular conditions effective May 1, 2021. Please be advised that prior authorization will continue to be required for these drugs. We apologize for any inconvenience.
Drug
|
Code
|
Code description
|
*Avastin
|
C9257
J9035
|
intravitreal bevacizumab
|
*Mvasi
|
Q5107
|
bevacizumab-awwb
|
*Zirabev
|
Q5118
|
bevacizumab-bvzr
|
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, 2021, 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 National Drug Code (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 information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
**ING-CC-0186
|
J3490, J3590, J9999
|
Margenza
|
*ING-CC-0187
|
J3490, J3590, J9999
|
Breyanzi
|
*ING-CC-0188
|
J3490, J3590
|
Imcivree
|
*ING-CC-0189
|
J3490, J3590, C9399
|
Amondys 45
|
*ING-CC-0190
|
J3490, J3590, C9399
|
Nulibry
|
**ING-CC-0094
|
J9304
|
Pemfexy
|
**ING-CC-0075
|
J3590, J9999, C9399
|
Riabni
|
Prior authorization update – change in clinical criteria
Coding Update: Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.
Quantity limit updates
Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
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.
To access the Clinical Criteria information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
*ING-CC-0189
|
J3490. J3590, C9399
|
Amondys 45
|
*ING-CC-0190
|
J3490, J3590, C9399
|
Nulibry
|
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. Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Empire BlueCross BlueShield (Empire)-contracted laboratories and identify the proper CPT® codes to use. Contact your Empire representative for additional information or visit https://www.empireblue.com/medicareprovider.
Refer patients to https://www.empireblue.com to find convenient testing locations
If an Empire member requests a COVID-19 test, you may refer them to Empire to find a testing location near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:
- Appointment or walk-in
- Drive through service
- Rapid test results
- Antibody testing
- Testing for children
Consider Antigen testing as an option when rapid results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), (for example, PCR). Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
Send swab tests to Empire-contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high value healthcare.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).
Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines. Part of the AIM Specialty Health®* (AIM) guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe and affordable healthcare services.
Joint surgery (updates by section):
- Further defined criteria for home physical therapy.
- Removed cognitive behavioral therapy as a conservative care modality for extremity.
- Added indication for diagnostic arthroscopy.
- Standardized radiographic criteria to align with lateral release criteria.
- Adhesive capsulitis — Added history of trauma or postoperative contracture as a requirement.
- Tendinopathy — Removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for superior labral tear anterior to posterior repair or have suggestive MRI findings.
- Hip athroscopy — Removed complementary alternative medicine as not typically done for the hip.
- Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) — Removed age as an exclusion for FAIS, but further defined radiographic exclusions.
- Unicompartmental knee arthroplasty/partial knee replacement — Added degenerative change of the patellofemoral joint as a contraindication.
- Arthroscopically assisted lysis of adhesions — Added ligamentous or joint reconstruction criteria.
- Added criteria for plica resection.
Spine surgery (updates by section):
- Further defined criteria for home physical therapy.
- Added standard conservative management requirement for instability to align with spinal stenosis indications.
- Added new comprehensive indication for tethered cord syndrome.
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* Portal at www.availity.com.
- Call the AIM Contact Center toll-free number at 1-800-714-0040 between 7 a.m. and 7 p.m. Eastern time.
Questions
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 here.
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. We offer webinars on a variety of topics, including medical coding, claims issues, quality measures, healthcare and more. Each live webinar may offer both continuing medical education (CME)/continuing education unit (CMU) credit for attendees. On-demand recordings are also available (with CME credit) for your convenience.
Sign up for a session here today!
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).
Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines. Part of the AIM Specialty Health®* (AIM) guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe and affordable healthcare services.
Joint surgery (updates by section):
- Further defined criteria for home physical therapy.
- Removed cognitive behavioral therapy as a conservative care modality for extremity.
- Added indication for diagnostic arthroscopy.
- Standardized radiographic criteria to align with lateral release criteria.
- Adhesive capsulitis — Added history of trauma or postoperative contracture as a requirement.
- Tendinopathy — Removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for superior labral tear anterior to posterior repair or have suggestive MRI findings.
- Hip athroscopy — Removed complementary alternative medicine as not typically done for the hip.
- Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) — Removed age as an exclusion for FAIS, but further defined radiographic exclusions.
- Unicompartmental knee arthroplasty/partial knee replacement — Added degenerative change of the patellofemoral joint as a contraindication.
- Arthroscopically assisted lysis of adhesions — Added ligamentous or joint reconstruction criteria.
- Added criteria for plica resection.
Spine surgery (updates by section):
- Further defined criteria for home physical therapy.
- Added standard conservative management requirement for instability to align with spinal stenosis indications.
- Added new comprehensive indication for tethered cord syndrome.
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* Portal at www.availity.com.
- Call the AIM Contact Center toll-free number at 1-800-714-0040 between 7 a.m. and 7 p.m. Eastern time.
Questions
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 here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Empire BlueCross BlueShield HealthPlus (Empire)-contracted laboratories and identify the proper CPT ® codes to use. Contact your Empire representative for additional information or visit https://providerpublic.empireblue.com.
Refer patients to www.empireblue.com/ny to find convenient testing locations
If an Empire member requests a COVID-19 test, you may refer them to Empire to find a testing location near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer
- Appointment or walk-in
- Drive through service
- Rapid test results
- Antibody testing
- Testing for children
Consider Antigen testing as an option when rapid results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), (for example, PCR). Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
Send swab tests to Empire-contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high-value healthcare.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Metabolic monitoring for children and adolescents on antipsychotics (APM)
The Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) HEDIS® measure evaluates the percentage of children and adolescents 1 to 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.
Antipsychotic medications can increase a child’s risk for developing health concerns, including metabolic health complications. The goal of this measure is for members to have metabolic monitoring by having both a blood glucose test (glucose or HbA1c) and LDL-C testing annually.
Record your efforts:
- Glucose test or HbA1c test and LDL-C cholesterol test as identified by claim/encounter
- Document results in the member’s medical record
Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications (SSD)
The Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) HEDIS measure evaluates members 18 to 64 years of age with schizophrenia, schizoaffective disorder or bipolar disorder, and who were dispensed an antipsychotic medication and had a diabetic screening test during the measurement year.
Diabetes screening is important for anyone with schizophrenia or bipolar disorder. The added risk associated with antipsychotic medications contributes to the need to screen people with schizophrenia for diabetes annually.
Record your efforts:
- Glucose test or HbA1c test as identified by claim/encounter
- Document results in the member’s medical record
Helpful tips:
- Educate patients and their caregivers on the importance of completing blood work annually.
- If your practice uses electronic medical records (EMRs), have flags or reminders set in the system to alert when a patient is due for screenings.
- Draw labs in your office, if available, or refer members to a participating lab for screenings.
- Follow up on laboratory test results and document in your chart.
- Share EMR data with Empire BlueCross BlueShield HealthPlus (Empire) to capture all coded elements.
Other available resources:
- Clinical Practice Guidelines are available on our provider website at https://providerpublic.empireblue.com.
- For the Quality Measures Desktop Reference for Medicaid Providers and HEDIS Benchmarks and Coding Guidelines for Quality Care, contact Empire Provider Services.
For more information, call Provider Services at 1-800-450-8753 or contact your local Provider Solutions representative.
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