 Provider News New YorkMay 2023 Provider News Contents
NYBCBS-CDCRCM-023177-23 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Moving Toward Equity in Asthma Care CME Training and Asthma Medication Ratio HEDIS measure update Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Moving Toward Equity in Asthma Care Empire BlueCross BlueShield is committed to achieving health equity in asthma outcomes with diverse populations. As part of this commitment, we offer an online training, Moving Toward Equity in Asthma Care. This course is accessible from any mobile device or computer and provides one continuing medical education credit at no cost to you. Visit www.mydiversepatients.com. Asthma Medication Ratio (AMR) HEDIS® measure The National Committee for Quality Assurance (NCQA) is also working to identify and reduce disparities in care. As part of this effort, race and ethnicity stratifications were added to the AMR HEDIS metric this year. The AMR metric measures the percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year. Did you know: - Hispanics and African Americans with asthma are less likely to take daily controllers and are more likely to visit the ER and be hospitalized for asthma-related conditions than non-Hispanic whites? 1
- Asian Americans are more likely to die from asthma than non-Hispanic whites?2
- Appropriate medication management for patients with asthma could reduce the need for rescue medication — as well as the costs associated with ER visits, inpatient admissions, and missed days of work or school?
Helpful tips: - Ensure at least half of the medications dispensed to treat asthma are controller medications throughout the measurement period.
- Talk to the patient about the importance of controller medication compliance, and not to use rescue medications on a regular basis, unless part of asthma action plan.
- Encourage patients to fill their prescriptions on a regular schedule rather than waiting till they are symptomatic.
- Create a written asthma action plan in language the patient understands, and schedule follow-up appointments with patients. Ask patients questions to assess asthma control, adherence to the action plan, and identify
- Utilize evidence-based asthma assessment tools to assess asthma control, adherence to the action plan, and identify triggers.
- Take the Moving Toward Equity in Asthma Care CME course at no cost for more helpful tips.
Additional resources
Also available is the Asthma & Me training. Do your patients have asthma? Show them the pathophysiology of asthma in their preferred language. References: - Asthma and Allergy Foundation of America & National Pharmaceutical Council. (2005). Ethnic Disparities in the Burden and Treatment of Asthma. Retrieved from http://www.aafa.org/media/Ethnic-Disparities-Burden-Treatment-Asthma-Report.pdf
- U.S. Department of Health & Human Service, Office of Minority Health. (2016, May 9). Asthma and Asian Americans. Retrieved August 8, 2016, from https://www.minorityhealth.hhs.gov
- Asthma and Allergy Foundation of America. (2020). Asthma Disparities in America: A Roadmap to Reducing Burden on Racial and Ethnic Minorities. Retrieved from: https://aafa.org/wp-content/uploads/2022/08/asthma-disparities-in-america-burden-on-racial-ethnic-minorities.pdf
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective July 1, 2023, specialty pharmacy site of care reviews will be required for New York State Health Insurance Program (NYSHIP) Empire Plan members. Empire Plan members are billed under the dedicated prefix YLS. Empire BlueCross BlueShield administers the Empire Plan Hospital Program. Pre-determination clinical review of non-oncology use of specialty pharmacy drugs is managed by the clinical team dedicated to Empire Plan members: - Access our Clinical Criteria to view the complete information for these predetermination requests.
Important note: Currently your Empire Plan patients may receive infusions of these medications without prior authorization or predetermination of benefits. As of the effective date below, it is strongly recommended you request a predetermination of benefits for your patients’ continued infusions of these medications. Effective for dates of service on and after July 1, 2023, the specialty pharmacy codes from current or new Clinical Criteria documents will be included in our site of care review process: - Access our Clinical Criteria to view the complete information for these site of care updates and to view the complete list of drugs subject to site of care review.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In June 2023, Empire BlueCross BlueShield (Empire) will replace our legacy internal provider data management system for Empire contracted providers. This investment in advanced technology will significantly improve data accuracy and transparency — enhancing the overall provider experience. New system features strengthen Empire’s ability to match submitted claims for more accurate pricing and processing. System upgrades special notice Empire will implement system upgrades beginning May 30, 2023. Provider updates submitted during this time will be processed after June 6, 2023. We appreciate your patience as we upgrade our systems. Critical billing requirements As part of this system upgrade, Empire is enforcing the billing guidelines of CMS that hold providers accountable for billing claims data correctly. (See link below to CMS Regulations and Guidance.) Effective December 9, 2023, claims submitted with missing or incorrect billing NPI will be rejected and returned. Submitting claims with complete and correct data is critical to ensure Empire is able to process your claims efficiently and accurately. All data fields on claims are used when building your claim records. You should bill according to standard billing guidelines. As we approach the implementation date for our strategic provider system, we encourage you to review your billing practices carefully to ensure proper TIN, billing NPI, and rendering provider information (if applicable) are submitted in the appropriate fields. As a reminder, if claims are submitted incorrectly, they will be rejected and returned for correction. Electronic claims filing If you are filing professional claims electronically (supported by electronic data interchange [EDI]), below are some tips for a successful claim submission: - Billing provider— Loop (section) 2010:
- When the billing provider is an organization healthcare provider, the organization’s NPI number is reported in field NM109.
- The TIN of the billing provider must be reported in the REF segment of this loop.
- The billing provider may be an individual only when the healthcare provider performing the services is an independent, unincorporated entity.
- The billing provider address must hold a physical address and should not contain any of the following: Post Office Box, P.O. Box, PO Box, Lock Box, or Lock Bin.
- Rendering provider— Loop 2310:
- This loop or section of the EDI file is required when the rendering provider’s NPI is different from that carried in Loop ID-2010AA-billing provider. If not required by the EDI implementation guide, do not send.
- The rendering provider is the person or company who rendered the care.
Mail claims filing If you are filing a professional claim via mail: - Facility information:
- Include the address of the servicing facility — the address where services were rendered — in Box 32.
- Include the servicing facility’s NPI — service location NPI — in Box 32a.
- Billing provider:
- The billing provider’s complete name, address, and phone number must be in Box 33.
- NPI must be reported in Box 33a (group’s organization or individual provider is an independent, unincorporated entity).
- The TIN of the billing provider must be reported in Box 25.
- Rendering provider:
- For claims that require a rendering provider, report the rendering provider NPI in Box 24J.
If using a clearinghouse, we suggest that you contact the clearinghouse to ensure proper claims filing and to alert the vendor of Empire’s upcoming system change. Regular check-ins with your clearinghouse are key to identifying claim issues early. Critical data requirements Please ensure that all your contracted providers are submitted to Empire and are on file prior to rendering services. This will alleviate claim processing delays and helps to ensure the Provider Directory reflects correct information. It is a contractual requirement to submit physicians joining your group in a timely manner, prior to the physician rendering care to members. Looking ahead Going forward, we will continue to share information about our plans to move to the strategic provider system and the impact to our care provider partners. Watch for upcoming editions of Provider News. For more information, review: Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting empireblue.com/provider, then under Provider Overview, select Find Care. Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include: - Add/change an address location
- Name change
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the form, we will send you an email acknowledging receipt of your request. The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current.
NYBCBS-CM-022694-23-CPN22692 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’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. Engagement Hub objectives: - Learn strategies to help you and your care team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
- Offer care providers a convenient way to earn CME credits at a time that works best for you.
Register here for our free CME clinical quality webinars! Note: Sessions in this series are approved for one American Academy of Family Physicians credit each. NYBCBS-CRCM-023026-23-CPN22728 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective May 1, 2023, we will enhance the Provider News website and email communications as part of our commitment to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year. Stay tuned for more updates. View the Quick Reference Guide for more information. NYBCBS-CDCRCM-016126-22-CPN15788 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Digital Request for Additional Information (Digital RFAI) is coming soon. When your organization registered to use the Medical Attachments application through Availity Essentials,* you also registered to receive digital notifications through that application. This makes it possible for Empire BlueCross BlueShield (Empire) to notify you digitally when we need documents to process your claim. Beginning June 1, 2023, Empire will notify you through your Attachments Dashboard when we need medical records, itemized bills, or other documents required to process our Commercial member claims. You will no longer receive a paper letter or remittance advice when we need documents to process most claims. Enabling more efficient processes Each morning, you will receive Digital RFAI notifications in your Attachments Dashboard Inbox for claims we are unable to process because we need supporting documentation. For certain claim types, we will pend the claim, rather than deny. You will have 30 days from the notification to digitally submit the needed attachments. If we don’t receive the needed attachments within 30 days, the claim will then deny, and you will receive a remittance advice. An additional notification will be posted to your Attachments Dashboard Inbox for up to 45 days to allow you to attach the documents to the notification. How to prepare to receive digital notifications: - Check your Medical Attachments application registration:
- If you are already registered to use the Medical Attachments application, make sure all your billing NPIs are correctly registered.
- Ask your Availity administrator to verify your registration.
- Use the self-service learning module to help your Availity administrator check your registration.
- Check your staff’s security:
- All team members needing access to attachment information should have these role assignments:
- Claims Status
- Medical Attachments
- Ask your Availity administrator to confirm all the role assignments are correctly applied to the right team members. They need to have access to the organization ID (customer ID) for which the billing NPIs are registered.
- Use the self-service learning module to help your Availity administrator check your team members role assignments.
Help, training, and support In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration: Date | Start time | April 24, 2023 | 2 p.m. Eastern time | April 28, 2023 | 2 p.m. Eastern time | May 10, 2023 | 2 p.m. Eastern time |
Availity administrators can use this link to register for live training or to view the live training. For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient: Date | Start time | May 11, 2023 | 2:30 p.m. Eastern time | May 12, 2023 | 11 a.m. Eastern time | May 15, 2023 | 11 a.m. Eastern time |
Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training or to view the live training. Through this efficient process, we are receiving needed support documentation 50% faster than through the outdated method of mailing letters and receiving attachments through non-digital methods.1 If you are using the PWK process to submit attachments, you may still receive Digital RFAI notifications in your dashboard, if: - You didn’t send us the correct document.
- We need additional documents.
- The PWK attachment wasn’t received within seven days.
Resources available Use the helpful resources for information that can help for a smooth transition to Digital RFAI notifications: For additional resources, call Availity Client Services at 800-282-4548. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. NYBCBS-CM-023001-23-CPN22936 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For professional claims submitted on a CMS-1500 form processed on or after June 1, 2023, Empire will enhance our editing systems to automate edits and simplify remittance messaging. These edit enhancements are supported by correct coding guidelines, as documented in industry sources such as Correct Procedural Terminology (CPT®) guidelines and Centers for Medicare & Medicaid Services (CMS). Additionally, these edit enhancements will promote faster claim processing and reduce follow-up audits and/or record requests for claims that are not consistent with correct coding guidelines. As a result of these edit enhancements, there will be greater attention on identifying inappropriate billing of genetic testing services. Below are examples of claim edits focused on identifying inappropriate billing of genetic testing services that will be automated: - Multianalyte Assays with Algorithmic Analyses (MAAA) — CPT 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary Harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
- Panel testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists.
Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual. If you have questions on this program, contact your Provider Relationship Account Manager. NYBCBS-CDCM-015737-22-CPN14440 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 Medical Policies and Clinical Guidelines for Empire BlueCross BlueShield (Empire). The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline 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 service is 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 https://www.empireblue.com. Note: These updates may not apply to all administrative services only accounts as some accounts may have nonstandard benefits that apply. To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program FEP®), visit www.fepblue.org > Policies & Guidelines. Medical Policy updates New Medical Policy effective August 5, 2023 The following policy is new: - MED.00145 Digital Therapy Devices for Treatment of Amblyopia
Revised Medical Policy effective August 5, 2023 The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational: - MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
Revised Medical Policy effective August 12, 2023 The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational: - SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
Clinical Guideline updates Revised Clinical Guideline effective August 12, 2023 The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary: - CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective August 1, 2023, Empire BlueCross BlueShield will transition the clinical criteria for medical necessity review of MRI Breast to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines: - Oncologic Imaging
- Chest Imaging
As part of this transition of clinical criteria, the following procedures will be subject to prior authorization at Carelon Medical Benefits Management: CPT® code | Description | 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; unilateral | 77049 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; bilateral |
HCPCS | Description | C8903 | Magnetic resonance imaging with contrast, breast; unilateral | C8905 | Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral | C8906 | Magnetic resonance imaging with contrast, breast; bilateral | C8908 | Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral |
Access Carelon Medical Benefits Management’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. For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CM-021984-23-CPN21926 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after August 1, 2023, Empire BlueCross BlueShield will implement a new facility reimbursement policy titled Bundled Supplies and Services – Facility. This policy identifies certain services and/or supplies ineligible for separate reimbursement when reported by a facility. These identified services and/or supplies are an integral component to the overall procedure. The Related Coding section of the policy lists and describes the Current Procedural Terminology (CPT®) and Healthcare Common Procedural Coding System (HCPCS Level II) codes that are considered always bundled and not eligible for reimbursement when they are reported as a stand-alone service, or with another service. No modifiers will override the denial for the always bundled services and/or supplies. For specific policy details, visit the reimbursement policy page at empireblue.com. NYBCBS-CM-022957-23-CPN22784 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after August 1, 2023, Empire BlueCross BlueShield’s Robotic Assisted Surgery – Professional reimbursement policy will expand to include CPT® codes for computer-assisted surgical systems. This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed. The Related Coding section of the policy has been updated to include the following computer assisted surgical musculoskeletal navigation procedures: - 0054T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
- 0055T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
- 20985: Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)
The policy has been renamed to Technology Assisted Surgical Procedures – Professional and Facility, which defines both robotic assisted and computer assisted techniques. For specific policy details, visit the reimbursement policy page at empireblue.com. NYBCBS-CM-022962-23-CPN22785 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after August 1, 2023, Empire BlueCross BlueShield’s Multiple and Bilateral Surgery Processing – Professional reimbursement policy will be updated to include two new CPT® codes for the Esophagogastroduodenoscopy (EGD) code family. This policy allows reimbursement for multiple and bilateral procedures. Reimbursement is based on Centers of Medicare & Medicaid (CMS) standard multiple and bilateral procedure rules for multiple arthroscopic and endoscopic surgical procedures. The Related Coding section has been updated to include the following new CPT codes released by CMS for the Esophagogastroduodenoscopy (EGD) code family: - 43290 — Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon:
- Added CPT code 43290 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent
- 43291 — Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s):
- Added CPT code 43291 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent
For specific policy details, visit the reimbursement policy page at empireblue.com. NYBCBS-CM-022969-23-CPN22812 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Specialty pharmacy updates for Empire BlueCross BlueShield (Empire) are listed below. Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Empire’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* a separate company. Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications. Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code. Prior authorization updates Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process. Access our Clinical Criteria to view the complete information for these site of prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | J9999 | CC-0062 | Idacio (adalimumab-aacf) | J3490, J3590 | CC-0231 | Lamzede (velmanase alfa-tycv) | C9399, J3490 | CC-0232* | Lunsumio (mosunetuzumab-axgb) | C9399, J3490, J3590, J9999 | CC-0233 | Rebyota (fecal microbiota, live – jslm) | C9399, J3490, J3590 | CC-0234 | Syfovre (pegcetacoplan) | C9399, J3490 | CC-0116* | Vivimusta (bendamustine) | J9999 |
* Oncology use is managed by Carelon Medical Benefits Management, Inc. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Site of care updates Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our site of care review process. Access our Clinical Criteria to view the complete information for these site of care updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0217 | Amvuttra (vutrisiran) | J0225 | CC-0194 | Cabenuva (cabotegravir extended-release; rilpivirine extended-release) | J0741 | CC-0003 | Cutaquig (immune globulin) | J1551 | CC-0210 | Enjaymo (sutimlimab-jome) | J1302 | CC-0018 | Nexviazyme (avalglucosidase alfa-ngpt) | J0219 | CC-0019 | Reclast (zoledronic acid) | J3489 | CC-0075 | Riabni (rituximab-arrx) | Q5123 | CC-0075 | Ruxience (rituximab-pvvr) | Q5119 | CC-0202 | Saphnelo (anifrolumab-fnia) | J0491 | CC-0212 | Tezspire (tezepelumab-ekko) | J2356 | CC-0075 | Truxima (rituximab-abbs) | Q5115 | CC-0207 | Vyvgart (efgartigimod alfa-fcab) | J9332 | CC-0220 | Xenpozyme (olipudase alfa) | J0218 |
Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be removed from our site of care review process. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0004 | Acthar (corticotropin) | J0800 | CC-0034 | Berinert (C1 Esterase Inhibitor, Human) | J0597 | CC-0034 | Firazyr (icatibant) | J1744 | CC-0154 | Givlaari (givosiran) | J0223 | CC-0034 | Kalbitor (ecallantide) | J1290 | CC-0013 | Mepsevii (vestronidase alfa) | J3397 | CC-0073 | Prolastin-C (alpha-1 proteinase inhibitor) | J0256 | CC-0156 | Reblozyl (luspatercept) | J0896 | CC-0034 | Ruconest (C1 Esterase Inhibitor, Recombinant) | J0596 |
Quantity limit updates Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process. Access our Clinical Criteria to view the complete information for these quantity limit updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | J9999 | CC-0062 | Idacio (adalimumab-aacf) | J3490, J3590 | CC-0231 | Lamzede (velmanase alfa-tycv) | C9399, J3490 | CC-0233 | Rebyota (fecal microbiota, live – jslm) | C9399, J3490, J3590 | CC-0234 | Syfovre (pegcetacoplan) | C9399, J3490 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CM-022991-23-CPN22815 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Medical Specialty Drug Review team of Empire BlueCross BlueShield will manage the pre-service clinical review of non-oncology specialty pharmacy drugs. Carelon Medical Benefits Management, Inc.,* a separate company, will manage oncology drugs. The following Clinical Criteria documents were endorsed at the February 24, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link. New Clinical Criteria effective August 1, 2023 The following Clinical Criteria are new: - CC-0230 Adstiladrin (nadofaragene firadenovec-vncg)
- CC-0233 Rebyota (fecal microbiota, live – jslm)
Revised Clinical Criteria effective August 1, 2023 The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary: - CC-0062 Tumor Necrosis Factor Antagonists
- CC-0086 Spravato (esketamine) Nasal Spray
- CC-0096 Asparagine Specific Enzymes
- CC-0110 Perjeta (pertuzumab)
- CC-0115 Kadcyla (ado-trastuzumab)
- CC-0116 Bendamustine agents
- CC-0119 Yervoy (ipilimumab)
- CC-0120 Kyprolis (carfilzomib)
- CC-0128 Tecentriq (atezolizumab)
- CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. NYBCBS-CM-022601-23 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Please continue to check for the latest Medicaid information including: Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For professional claims submitted on a CMS-1500 form processed on or after June 1, 2023, Empire BlueCross BlueShield will enhance our editing systems to automate edits and simplify remittance messaging. These edit enhancements are supported by correct coding guidelines as documented in industry sources such as Correct Procedural Terminology (CPT®) guidelines and Centers for Medicare & Medicaid Services (CMS). Additionally, these edit enhancements will promote faster claim processing and reduce follow-up audits and/or record requests for claims that are not consistent with correct coding guidelines. As a result of these edit enhancements, there will be greater attention on identifying inappropriate billing of genetic testing services. Below are examples of claim edits focused on identifying inappropriate billing of genetic testing services that will be automated: - Multianalyte Assays with Algorithmic Analyses (MAAA) — CPT 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
- Panel testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists.
Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual. If you have questions on this program, contact your Provider Relationship Account Manager. NYBCBS-CR-019034-23-CPN18337 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Who is affected For women ages 67 to 85 who sustained a recent fracture, it is important to obtain a bone density scan to assess for osteoporosis. How can we collaborate? We can help your patients complete this scan in the comfort of their home through Quest Health Connect. In home resources We are working with Quest HealthConnect™,* a Quest Diagnostics service, to provide this service at no added cost to you. Quest HealthConnect will call your patient to arrange a visit. Patients may also call them directly at 888-306-0615 between 8:30 a.m. to 4 p.m. Eastern Time. The result(s) of the screening test(s) will be sent to both the patient and your office after the visit. * Quest Diagnostics is an independent company providing preventive care technology and health risk assessments services on behalf of the health plan. NYBCBS-CR-017878-23-CPN17332 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The fax number on the previous communication was incorrect and has been corrected here. The correct fax number is 833-678-0223. For services beginning on July 1, 2023, prior authorization requests for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services will be reviewed by Carelon Post Acute Solutions, LLC.* The goal of this program is to ensure members receive the right product for the right duration of time in the home. This change will be applicable to the following markets: New York. How to submit or check a prior authorization request For DMEPOS services, Carelon Post Acute Solutions will begin receiving requests on Tuesday, June 20, 2023, for dates of service July 1, 2023, and after. Providers are encouraged to request authorization using the website. Go here to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions at 833-678-0223. Please note: Carelon Post Acute Solutions will not review authorization requests for products/services that do not fall under Medicare-covered products/services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras. To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit the website or email. If you have additional questions, please call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622. * Carelon Post Acute Solutions, LLC is an independent company providing services on behalf of the health plan. NYBCBS-CR-024047-23-CPN24014 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Please continue to read the latest Medicare Advantage information, including: |