Blue High-Performance Networks® (BlueHPN) first went live January 1, 2021 in more than 50 cities across the country. Since then, our national customer base has grown. This fall, major employers will offer plans with access to our BlueHPN for the 2022 benefit year.

 

BlueHPN is a national network designed from our local market expertise and strong provider relationships, aligned with local networks across the country. These local networks are connected to the national chassis to form a national BlueHPN network.

 

In New York, Empire BlueCross BlueShield (“Empire”) is offering large and small group employers plans with access to the BlueHPN, with the existing Connection network as the New York HPN entry.

 

Member ID cards and other plan material will feature one small change for 2022: BlueHPN is now a single word rather than two.

 

As has been the case this year, in 2022 you may see patients accessing the BlueHPN/Connection network through EPO plans or HSA plans with an EPO network. Under these plans, out of network benefits are limited to emergency or urgent care. Be sure to continue to verify patient eligibility and benefits.

 

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The 32BJ Health Fund remains committed to providing 32BJ members and their eligible dependents with access to high-quality, low-cost health care that delivers excellent results. To that end, the 32BJ Health Fund has partnered with hospitals and providers in New York, New Jersey, Connecticut, Massachusetts, Pennsylvania, and Florida to implement a Centers of Excellence (COE) Program for Bariatric and Joint Replacement surgeries starting on January 1, 2022.

 

Important features of the program include:

• Coverage for 32BJ members: 32BJ Health Fund plan participants will only have coverage for their bariatric or joint replacement procedures when performed by a COE-participating provider at a COE hospital. Participants will have a $0 copay for the procedure and follow-up care within 30 days. There will be no coverage for bariatric and joint replacement surgeries performed by a non-COE provider or at a non-COE hospital.
• To locate a COE provider and COE hospital: Plan participants may call 32BJ Member Services at (800) 551-3225. Providers may call Empire Provider Services at (800) 676-2583.
• Distance threshold: 32BJ plan participants living within 50 miles of a COE hospital must have their surgery performed by a COE provider at a COE hospital. More than 90% of 32BJ members live within 50 miles of a COE hospital.

 

You can easily identify 32BJ plan participants by the unique prefix on their Empire ID, “ETRBJ.”

 

Any provider looking for more information—particularly anyone currently caring for 32BJ plan participants who may be candidates for bariatric or joint replacement surgery—should call Empire Provider Services at 1-800-676-2583.

 

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In an ongoing effort to promote accurate claims processing and payment, Empire BlueCross BlueShield (“Empire”) prefers the referring physician name and national provider identifier (NPI)to be included on professional home infusion therapy services claims in field 17 and 17a on CMS1500 claim forms.

Providers should report the referring physician information in accordance with the Empire guidelines in the EDI Companion Guide for electronically submitted claims.

 

If you have questions regarding this process, please contact your local Network Management Consultant.

 

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

 

For 2021, Empire will begin requesting medical records in January 2022. No special authorization is needed for you to share member medical record information with us, since quality assessment and improvement activities is a routine part of healthcare operations.

 

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

 

Ways to submit your records:

• Remote EMR Access Service – New!
  As we published in the September edition of Provider News, we now offer the Remote EMR Access Service to providers to submit member medical record information to Empire. If you are interested in more information, please contact us at Centralized_EMR_Team@anthem.com.
• Upload to our secure portal
  Medical records can be uploaded to Empire’s secure portal using the instructions in the request document.
• Fax
  Medical records can be faxed to Empire using the instructions in the request document.
• Mail
  Medical records can be mailed to Empire using the instructions in the request document.

 

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

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

1382-1121-PN-NY

 

We recently offered a series of CME webinars on a variety of topics. If you missed any of them, you can still register for the recorded webinars and earn CME credits. The webinars offer best practices to overcoming barriers in achieving clinical quality goals and attaining better patient outcomes. We also expect to offer more live CME webinars in the coming weeks.

• 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.

 

Attendees will receive one CME credit upon answering required questions at the conclusion of each webinar.

 

Register here for our upcoming live and on-demand clinical quality webinars!                  

 

1391-1121-PN-NY

The HEDIS® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality health-care services. 

 

The ECDS Reporting Standard provides a method to collect and report structured electronic clinical data for HEDIS quality measurement and improvement. 

 

Benefits to providers:

• Reduced burden of medical record review for quality reporting
• Improved health outcomes and care quality due to greater insights for more specific patient-centered care

ECDS reporting is part of the National Committee for Quality Assurance (NCQA’s) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures. 

 

Click here to learn more about NCQA’s digital quality system and what is means to you and your practice.

 

ECDS Measures

The first publicly reported measure using the HEDIS® Electronic Clinical Data System (ECDS) reporting standard is the Prenatal Immunization Status (PRS) measure. In 2022, NCQA will include the PRS measure in Health Plan Ratings for Medicaid and Commercial plans for measurement year 2021.

 

For HEDIS Measurement Year 2022, the following measures can be reported using ECDS: 

• Childhood Immunization Status CIS-E*
• Immunizations for Adolescents IMA-E*
• Breast Cancer Screening BCS-E
• Colorectal Cancer Screening COL-E
• Follow-Up Care for Children Prescribed ADHD Medication ADD-E
• Metabolic Monitoring for Children and Adolescents on Antipsychotics APM-E*
• Depression Screening and Follow-Up for Adolescents and Adults DSF-E
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults DMS-E
• Depression Remission or Response for Adolescents and Adults DRR-E
• Unhealthy Alcohol Use Screening and Follow-Up ASF-E
• Adult Immunization Status AIS-E
• Prenatal Immunization Status PRS-E (Accreditation measure for 2021)
• Prenatal Depression Screening and Follow-Up PND-E
• Postpartum Depression Screening and Follow-Up PDS-E

 

*Indicates that this is the first year that the measure can be reported using ECDS

 

Of note, NCQA added the ECDS reporting method to three existing HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening and Follow-up Care for Children Prescribed ADHD Medication. Initially, the ECDS method will be optional which provides health plans an opportunity to report using the ECDS method while transitioning to ECDS only in the future.

 

Other sources:

HealthITgov: https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/health-information-exchange

 

1392-1121-PN-NY

 

Healthcare and mental healthcare professionals have a vital role in improving health and wellbeing in our communities by identifying and treating racial trauma and injustice experienced by the individuals we serve. At Empire BlueCross BlueShield (“Empire”), we are committed to addressing racism in our society through open discussions about trauma, injustice, and inequality. These conversations are critical to improving the wellbeing of all Americans and the communities in which we live and serve.

 

We can impact the injustice of racism together.

Empire has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to engage providers and associates in conversations on racial injustice, trauma, and inequality. Together, we are continuing to evolve the conversation and digging deeper on a quarterly basis to keep the dialogue going.

 

Our racial equity forums focus on:

• Exploring how racism impacts health outcomes.
• Discussing how to identify racism in your practice and how to be an ally to your patients.
• Recognizing implicit bias (we all have it!) and how it affects the care provided to your patients.
• Understanding the impact of prolonged exposure to racism on people of .
• Providing you with actionable resources recognize and reduce racism that may exist in your practice.

 

Since October 2020, Empire has sponsored four virtual forums: Racial Trauma in America, The Road to Allyship: Playing Your Part in Racial Equity, In Pursuit of Racial Equity: Deconstructing Bias Forum, and Exploring the Impact of Racial Trauma on the Health & Wellbeing of Children.

 

Please register for the next forum.

Equity, COVID, and Holidays: Coping with grief

December 8, 2021
4:00-5:30 PM EST

Register today!

 

Continuing education credits available for those who sign up and participate

 

The first step in doing your part to address racism is to recognize that it exists.

These conversations may feel uncomfortable at first, and that’s ok – this is how we will make progress together in creating a more just and equitable society.

  

*Motivo is an independent company providing a virtual forum on behalf of Empire.

 

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Each year, the CDC encourages healthcare professionals, patients, and families to learn more about antibiotics by promoting U.S. Antibiotic Awareness Week (USAAW). Highlighting the importance of improving antibiotic prescribing and use, USAAW brings these lifesaving drugs to the forefront.

 

With a focus on helping to fight antibiotic resistance, USAAW asks you to Be Antibiotic Aware¹ and share this information with your patients:

1. Antibiotics can save lives. When a patient needs antibiotics, the benefits outweigh the risks of side effects or antibiotic resistance.
2. Antibiotics aren’t always the answe Everyone can help improve antibiotic prescribing and use.
3. Antibiotics do not work on viruses, such as those that cause colds, flu, bronchitis, or runny noses.
4. Antibiotics are only needed for treating infections caused by bacteria, but even some bacterial infections get better without antibiotics, including many sinus infections and some ear infections.
5. Antibiotics will not make patient’s feel better if the illness is a virus. Respiratory viruses usually go away in a week or two without treatment.
6. If antibiotics are needed, they should be taken exactly as prescribed. Provide information about potential side effects, including those that could result in treatment.
7. Antibiotics are critical tools for treating life-threatening conditions.

 

Each year in the United States, more than 2.8 million infections occur from antibiotic-resistant bacteria. More than 35,000 people die as a result.

 

Measure up: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)

This HEDIS® measure looks at the percentage of members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. Visit the NCQA website for exceptions.

 

Description	CPT®/HCPCS/ICD-10
Acute Bronchitis	ICD-10: J20.3, J20.4, J20.5, J20.6, J20.7, J20.8, J20.9, J121.0, J21.1, J21.8, J21.9
Online assessments	CPT: 98970, 98971, 98972, 99422, 99423, 99457 HCPCS: G0071, G2010, G2012, G2061, G2062, G2063
Telephone visits	CPT: 98966, 98967, 98968, 99441, 99442, 99443

 

To learn more about antibiotic prescribing and use, visit www.cdc.gov/antibioticuse.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

¹CDC www.cdc.gov/antibiotic-use

 

1406-1121-PN-NY

 

More than 42 million Americans reach for cigarettes regularly, but almost 70 percent of them say they want to quit. What gives? Maybe the traditional ways to quit smoking, such as going cold turkey or wearing a nicotine patch haven’t worked for them in the past. Thankfully, there are plenty of new ways to kick the smoking habit. Here are five approaches to share with patients who are trying to quit.

 

1. Download a Quit Smoking App
   There are plenty of downloadable quit smoking apps ready to coach patients along the way. Many former smokers recommend the LIVESTRONG MyQuit Coach, a free app available on iTunes.
2. Start a Quit Reward Fund
   According to a study from The New England Journal of Medicine, putting money on the line can help smokers quit. Researchers found 15.7% of people successfully quit for at least six months when they were offered an $800 reward. Patients can set aside their own money as a deposit that they get back when they successfully quit.
3. Ask Human Resources about Resources
   Many employers offer smoking cessation programs, which offer cash rewards, savings on insurance or other perks for not taking a puff. According to the American Lung Association, up to 57% of their smoking cessation program participants reported quitting smoking by the end of the program. Freedom From Smoking®, offered by American Lung Association is an often recommended program.
4. Quit Smoking with Meditation
   For many smokers, the act of lighting up is automatic. But a Yale University study found meditating and practicing mindfulness can cancel that relationship and slash cravings. Recommend a mobile app like Stop Smoking – Mindfulness Meditation App to Cessation Smoking Support.
5. Consider Medication
   Over-the-counter nicotine patches are designed to lessen withdrawal symptoms and have been a go-to for decades. But if those haven’t worked prescription medications can reduce cravings or make smoking less enjoyable.

 

Measure Up! Medical Assistance with Smoking and Tobacco Use Cessation (MSC) HEDIS® measure looks at members 18 and older to assess different facets of providing medical assistance with smoking and tobacco use cessation:

• Advising smokers and tobacco users to quit
• Discussing cessation medications
• Discussing cessation strategies

 

Measure adherence is determined by member response through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey.

 

Sources:
https://quitsmokingcommunity.org/the-6-best-quit-smoking-apps/https://itunes.apple.com/us/app/livestrong-myquit-coach-dare/id383122255?mt=8&ign-mpt=uo%3D4http://www.nejm.org/doi/full/10.1056/NEJMoa1414293#t=articleDiscussionhttp://elischolar.library.yale.edu/cgi/viewcontent.cgi?article=1712&context=ymtdlhttps://itunes.apple.com/us/app/stop-smoking-mindfulness-meditation/id621443244?mt=8http://www.health.harvard.edu/blog/whats-best-way-quit-smoking-201607089935http://www.lung.org/support-and-community/corporate-wellness/help-employees-stop-smoking.html?referrer=https://www.google.com/

 

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Effective January 1, 2022, continuous glucose monitors (CGMs) will no longer be covered under the medical benefit as durable medical equipment for certain Empire BlueCross BlueShield (“Empire”) fully insured groups. For these members, CGMs will only be covered under their pharmacy benefit. This applies for both new prescriptions and refills.

 

We will notify affected members via mail. Members who need to transfer CGMs from their medical benefit to their pharmacy benefit will need a new prescription from their provider.

 

Note that some Empire groups will retain their medical DME coverage for CGMs and these members will have the option of using either the medical or pharmacy benefit. Generally, members receive their CGMs faster when obtained using their pharmacy benefit, so we encourage the use of the pharmacy benefit.

 

If you have questions, please contact Provider Services.

 

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Empire BlueCross BlueShield (“Empire”) covers annual wellness visits and well-woman visits at 100% with no member cost-sharing when provided by in-network providers for members that have ACA-compliant plans. Beginning January 1, 2022, Empire will encourage some ACA-compliant individual and small group plan members to schedule annual wellness visits or well-woman visits with their physician within the first 90 days of the plan renewal.

 

Some providers currently require patients to schedule wellness visits or well-woman visits at least one year past their most recent visit. This practice helps ensure a patient does not exceed more than one wellness visit per calendar year. Beginning January 1, 2022, providers can perform the annual wellness visit or well-woman visit for these members, even if it has been less than one year since the last wellness visit. The claim for the wellness visit or well-woman visit will be processed as a preventive care service covered at 100% as long as its billed accordingly.  

 

Please note, this benefit may not apply to all health plans. Providers should continue to verify eligibility and benefits for all members prior to providing services or receiving member copayments, deductibles, or coinsurance.

 

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New York state (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) plans, inclusive of Mainstream MMC Plans, HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs), as well as Health and Recovery Plan (HARP), have expanded current colorectal cancer screening coverage to include enrollees 45 to 49 years of age. This expansion is in response to recently updated recommendations by the United States Preventive Services Task Force (USPSTF). New information suggests earlier screening has a moderate net benefit and should be considered for individuals at average risk for colorectal cancer. The USPSTF continues to state, with high certainty, that screening for colorectal cancer in individuals 50 to 75 years of age have substantial net benefit. For additional information regarding colorectal cancer screening, providers can visit the USPSTF Colorectal Cancer: Screening web page.

Colorectal cancer is the third leading cause of cancer-related deaths in NYS, with almost 3,000 deaths reported in the state annually. Studies show that early detection can increase the five-year survival rate by as much as 75%. All Medicaid members between 45 to 75 years of age at average risk for colorectal cancer should be offered screening with one of the recommended screening test options. Screening members at high risk for colorectal cancer should be done sooner than screening of average risk individuals and should be based on clinical decision. Although cancer screening rates have increased over the last few years, it is estimated almost 30% of NYS residents between 50 to 75 years of age are not up to date with their colorectal cancer screening.

NYS Medicaid providers should notify all their adult patients about their risk for colorectal cancer and discuss screening test options with them. Studies show that patients are more likely to be screened for colorectal cancer if they are offered test options. Providers, taking patient preferences into consideration, may order the most appropriate colorectal cancer screening methods from Table 1. The recommended frequencies listed in Table 1 are for patients considered to be of average risk of developing colorectal cancer.

Table 1: Colorectal cancer screening methods for patients considered to be of average risk Method Recommended frequency Fecal immunochemical test (FIT) or high sensitivity fecal occult blood testing (FOBT) [Once annually FIT-DNA* (such as Cologuard) Once every three years Computed tomography colonography (CTC) Once every five years Flexible sigmoidoscopy (SIG) Once every 10 years Colonoscopy Once every 10 years SIG with FIT Once every 10 years (SIG) plus once every year (FIT)

* DNA - deoxyribonucleic acid, in this case based from stool and any blood shed therein.

 

Reminders:

• The colorectal cancer screening methods included in Table 1 may be used for individuals considered to be at high risk. In general, however, screening with colonoscopy is the preferred method for most individuals at high risk for colorectal cancer.
• More frequent colorectal cancer screening methods may be considered medically necessary for individuals considered to be at high risk of developing colorectal cancer.
• It is important to discuss with patients that positive results from the screening methods outlined in Table 1, other than colonoscopy, may result in the need for diagnostic colonoscopies.

• Colorectal cancers should be considered possible diagnoses in patients (regardless of age) presenting with blood in their bowel movements, changes in bowel habits, abdominal pains, weight losses, or unexplained anemias. In such situations, the USPSTF and the American Cancer Society^® (ACS) recommend clinical decision making to determine whether diagnostic colonoscopies should be performed.
• NYS Medicaid considers colorectal cancer screening by any method not listed above experimental and investigational at this time.

 

Questions and additional information:

• For more information and resources related to colorectal cancer screening, visit the NYS Department of Health (DOH) colorectal cancer web page at http://www.health.ny.gov/diseases/cancer/colorectal.
• Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management (DPDM) by phone at 518-473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee’s MMC plan. For MMC plan information, providers can visit the NYS Medicaid Program Information for All Providers – Managed Care Information document at: https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers_

           Managed_Care_Information.pdf, hosted on the eMedNY website.

 

NYE-NU-0363-21 September 2021

 

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

Availity* serves as our electronic data interchange (EDI) partner for all electronic data and transactions. The Availity EDI processing generates response files for each submitted electronic file and delivers them to the submitter’s Availity mailbox. It is important to review these responses to understand where your claims are in the process.

 

Electronic file submitter:

• If your organization uses a clearinghouse or vendor, they have an Availity mailbox to submit clients’ files. Availity delivers the responses for claims to the same mailbox, and the clearinghouse or vendor is responsible for returning the results to their clients and resubmitting any files rejected for formatting, interchange, or transaction set errors. The submitter in this scenario is the clearinghouse or vendor.
• If your organization uses a practice management software, an Availity mailbox is set up during initial registration for your electronic file submissions. The submitter is your organization and is responsible for analyzing the responses to verify there are not any file errors or claim rejections that require correction and resubmission within timely filing guidelines.

 

Availity electronic file process:

1. Submit electronic file to Availity — Availity validates for file format and returns file acknowledgments to the submitter’s Availity mailbox. If there are any edits at this point, the entire electronic file will not advance and will require resubmission within timely filing guidelines.
2. HIPAA and payer specific edits — The electronic file moves to the next phase, which is HIPAA and business editing. Examples include:
   • Valid subscriber ID for the date of service
   • Billing and coding validation
   • If an error occurs at this point, the individual claims with the errors must be corrected, resubmitted as an original claim and do not advance. The claims that do not have an edit will then route to the adjudication systems for second-level edit validation.
3. Empire payer receives electronic file from Availity — For the Medicaid and Medicare lines of business, there is a second level of editing.

Edits for this second level return the Delayed Payer Report (DPR). Only claims that pass will advance for adjudication and will be displayed using Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. If there are edits, the claim requires resubmission within timely filing guidelines.

 

Electronic responses

File acknowledgment — Indicates whether we receive an electronic file in the correct format and acceptance by Availity.

• Action required — If any errors occur at this stage, the submitter will need to correct and resubmit the entire electronic file to Availity.

 

Immediate Batch Response (IBR) — This report acknowledges accepted claims and identifies claim edits due to HIPAA and business edits. The report also includes claim counts and charges for the electronic file. Availity creates this file prior to routing accepted claims to the adjudication systems.

• Action required for claims with edits: Rejected claims require resubmission within timely filing guidelines and will not advance to the adjudication system that would display Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. Not applicable to denied claims.

 

Delayed Payer Report (DPR) — This report is currently only returned for the Medicaid or Medicare lines of business and contains second-level editing from the adjudication system after Availity has routed claims that passed on the IBR report.

• Action required for claims with edits: Rejected claims would need to be resubmitted and will not display on Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice and paper Explanation of Payment.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative call Availity Client Services with any questions at 1-800-AVAILITY (282-4548), or call Provider Services:

• Medicaid: 1-800-450-8753
• Medicare Advantage: Call the number on the back of members’ ID cards

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire.

 

NYE-NU-0338-21 August 2021

519370MUPENMUB

 

On August 21, 2020, November 20, 2020, and June 24, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

Effective date	Document number	Clinical Criteria title	New or revised
November 1, 2021	*ING-CC-0201	Rybrevant (amivantamab-vmjm)	New
November 1, 2021	*ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
November 1, 2021	*ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
November 1, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
November 1, 2021	ING-CC-0124	Keytruda (pembrolizumab)	Revised
November 1, 2021	*ING-CC-0102	GnRH Analogs for Oncologic Indications	Revised
November 1, 2021	ING-CC-0076	Nulojix (belatacept)	Revised
November 1, 2021	*ING-CC-0077	Palynziq (pegvaliase-pqpz)	Revised
November 1, 2021	ING-CC-0067	Prostacyclin Infusion and Inhalation Therapy	Revised
November 1, 2021	ING-CC-0194	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	Revised
November 1, 2021	*ING-CC-0174	Kesimpta (ofatumumab)	Revised
November 1, 2021	*ING-CC-0182	Agents for Iron Deficiency Anemia	Revised

NYE-NU-0352-21 September 2021

This is a reminder to all providers that we require laterality-specific coding when applicable. Therefore, claims processed on or after October 1, 2021, will be denied when ICD-10-CM laterality coding guidelines are not followed.

 

In accordance with the International Classification of Disease, 10th Revision, clinical modification
(ICD-10-CM) correct coding guidelines, in which state Medicaid programs follow, we will begin to edit diagnosis in Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue for appropriate laterality billing.

 

ICD-10-CM diagnosis coding falls under Health Insurance Portability and Accountability Act (HIPAA) correct code sets and they are designed to specifically define laterality (e.g., left, right, unspecified, or exists bilaterally, etc.). Providers are required to submit the defined code in accordance with the condition. The ICD-10-CM guidelines for Coding and Reporting state (for Laterality coding), “Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.”

 

The ICD-10-CM diagnosis code should correspond to the medical record, CPT^® and HCPCS code(s), and/or modifiers billed.

 

If you have questions about this communication or need assistance with any other item, call Provider Services at 800-450-8753.

 

NYE-NU-0354-21 September 2021

 

The American Cancer Society estimates there will be approximately 1,898,160 cancer cases diagnosed in 2021. That’s the equivalent of 5,200 new cases every day.¹ The good news is, patients say they are more likely to get screened when you recommend it. What else can you do to influence cancer screenings?²

1. Understand the power of the physician recommendation:
   • Your recommendation is the most influential factor in whether a person decides to get screened.
   • Patients are 90% more likely to get a screening when they reported a physician recommendation.
   • “My doctor did not recommend it,” is the primary reason for screening avoidance.
2. Measure the screening rates in your practice; it may not be as high as you think:
   • Set goals to get screening rates up.
   • Follow the HEDIS^® guidelines included in this article to help accurately track your care gap closures.
3. More screening doesn’t have to mean more work for you:
   • Reach out to us about available member data — We may be able to help identify those members who are due for screenings.
   • Develop a reminder system, which has been demonstrated to be effective, to remind you and staff that patients have screenings due.
4. Help members access benefit information about screenings to eliminate the cost barrier:
   • Log on to Availity.com^* and use the Patient Registration tab to run an Eligibility and Benefits Inquiry.
   • Members can access their benefit information by logging on to empireblue.com/ny and selecting the Benefits tab, or by using Empire HealthPlus mobile app.

Members earn rewards for screenings through the Healthy Rewards Program

Through Healthy Rewards, members receive incentives for completing certain screenings. They can redeem their reward dollars for retail gift cards — just another way we can work together for better health outcomes.

 

Screening	Reward	Timing
Breast Cancer Screening (BCS)	$50	Every two years
Cervical Cancer Screening (CCS)	$25	Every three years
Chlamydia Screening in Women (CHL)	$25	Annually

 

Measure up: Cancer screening for women HEDIS measure specifications

Organized and continuous screenings along with removal of precancerous lesions can lead to a 60% decrease in cervical cancer.³

Cervical Cancer Screening (CCS) is measured by the percentage of women 21 to 64 years of age who were screened for cervical cancer using one of the following criteria:

• Women 21 to 64 years of age who had cervical cytology performed within the last three years
• Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last five years
• Women 30 to 64 years of age who had cervical cytology/hrHPV co-testing within the last five years

 

Description and code

Cervical cytology lab test

CPT®: 88141-88143, 88147, 88148, 88150, 88152-88153, 88164-88167, 88174, 88175

HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091

LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

hrHPV lab test

CPT: 87620-87622, 87624-87625

HCPCS: G0476

LOINC: 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0

Absence of cervix diagnosis

ICD-10-CM: Q51.5, Z90.710, Z90.712

Hysterectomy with no residual cervix

CPT: 51925, 56308, 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58951, 58953, 58954, 58956, 59135

ICD-10-PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ

 

More women in the United States are surviving and thriving after breast cancer than ever before. In fact, in the last 30 years, the breast cancer death rate has dropped an astounding 40%. The decreases are believed to be the result of finding breast cancer earlier through screening, increased awareness, and better treatments.⁴

Breast Cancer Screening (BCS): The percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer. Compliant members have one or more mammograms any time on or between October 1, two years prior to the measurement year and December 31 of the measurement year.

 

Description

CPT/HCPCS

Mammography

CPT: 77061-77063, 77065-77067 LOINC: 24604-1, 24605-8, 24606-6, 24610-8, 26175-0, 26176-8, 26177-6, 26287-3, 26289-9, 26291-5, 26346-7, 26347-5, 26348-3, 26349-1, 26350-9, 26351-7, 36319-2, 36625-2, 36626-0, 36627-8, 36642-7, 36962-9, 37005-6, 37006-4, 37016-3, 37017-1, 37028-8, 37029-6, 37030-4, 37037-9, 37038-7, 37052-8, 37053-6, 37539-4, 37542-8, 37543-6, 37551-9, 37552-7, 37553-5, 37554-3, 37768-9, 37769-7, 37770-5, 37771-3, 37772-1, 37773-9, 37774-7, 37775-4, 38070-9, 38071-7, 38072-5, 38090-7, 38091-5, 38807-4, 38820-7, 38854-6, 38855-3, 42415-0, 42416-8, 46335-6, 46336-4, 46337-2, 46338-0, 46339-8, 46350-5, 46351-3, 46356-2, 46380-2, 48475-8, 48492-3, 69150-1, 69251-7, 69259-0

 

Sexual health is an essential element of overall health and well-being. Many patients want to discuss their sexual health with you, but most of them want you to bring it up. The National Coalition for Sexual Health has published a guide to help physicians feel comfortable about the conversation. Get a copy of the Sexual Health and Your Patients: A Provider’s Guide by clicking on the title or through this website: http://www.ctcfp.org.

Chlamydia Screening in Women (CHL) is measured by the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.

Description

CPT

Chlamydia tests

CPT: 87110, 87270, 87320, 87490, 87491, 87492, 87810 LOINC: 14463-4, 14464-2, 14467-5, 14474-1, 14513-6, 16600-9, 21190-4, 21191-2, 21613-5, 23838-6, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43405-0, 43406-8, 44806-8, 44807-6, 45068-4, 45069-2, 45075-9, 45076-7, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 4993-2, 50387-0, 53925-4, 53926-2, 557-9, 560-3, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 80360-1, 80361-9, 80362-7, 91860-7

 

¹ CA: A Cancer Journal for Clinicians. Cancer Statistics, 2021 https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21654

² http://thecanceryoucanprevent.org/wp-content/uploads/14893-80_2018-PROVIDER-PHYS-4-PAGER-11-10.pdf

³ National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/9253676/

⁴ Research to Help Women Prevent Breast Cancer or Live their best life with it. American Cancer Society. https://www.cancer.org/latest-news/research-to-help-women-prevent-breast-cancer-or-live-their-best-life-with-it.html

 

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 Empire BlueCross BlueShield HealthPlus.

NYEPEC-2936-21 September 2021

Please continue to check Medicaid Provider Communications & Updates at www.empireblue.com/nymedicaiddoc for the latest Medicaid information including:

• Medicaid continuous glucose monitoring systems
• Prior authorization updates for specialty pharmacy

 

We are offering webinars to help you understand the upcoming changes for City of New York retirees transitioning to the Medicare Advantage Plus plan from Empire BlueCross BlueShield on January 1, 2022. The webinars will review key operational processes such as determining eligibility and benefits, prior authorization requirements, and claims submissions to assist you in continuing to provide care for City of New York retirees. Please access the following invitation link to register for a webinar during the months of November, December, and January: https://empireblue.com/da/inline/pdf/ebscare-1086-21.pdf.

 

EBSCRNU-0200-21 September 2021

This communication applies to the Medicaid and Medicare Advantage programs for Empire.

 

Availity* serves as our electronic data interchange (EDI) partner for all electronic data and transactions. The Availity EDI processing generates response files for each submitted electronic file and delivers them to the submitter’s Availity mailbox. It is important to review these responses to understand where your claims are in the process.

 

Electronic file submitter:

• If your organization uses a clearinghouse or vendor, they have an Availity mailbox to submit clients’ files. Availity delivers the responses for claims to the same mailbox, and the clearinghouse or vendor is responsible for returning the results to their clients and resubmitting any files rejected for formatting, interchange, or transaction set errors. The submitter in this scenario is the clearinghouse or vendor.
• If your organization uses a practice management software, an Availity mailbox is set up during initial registration for your electronic file submissions. The submitter is your organization and is responsible for analyzing the responses to verify there are not any file errors or claim rejections that require correction and resubmission within timely filing guidelines.

 

Availity electronic file process:

1. Submit electronic file to Availity — Availity validates for file format and returns file acknowledgments to the submitter’s Availity mailbox. If there are any edits at this point, the entire electronic file will not advance and will require resubmission within timely filing guidelines.
2. HIPAA and payer specific edits — The electronic file moves to the next phase, which is HIPAA and business editing. Examples include:
   • Valid subscriber ID for the date of service
   • Billing and coding validation
   • If an error occurs at this point, the individual claims with the errors must be corrected, resubmitted as an original claim and do not advance. The claims that do not have an edit will then route to the adjudication systems for second-level edit validation.
3. Empire payer receives electronic file from Availity — For the Medicaid and Medicare lines of business, there is a second level of editing.

Edits for this second level return the Delayed Payer Report (DPR). Only claims that pass will advance for adjudication and will be displayed using Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. If there are edits, the claim requires resubmission within timely filing guidelines.

 

Electronic responses

File acknowledgment — Indicates whether we receive an electronic file in the correct format and acceptance by Availity.

• Action required — If any errors occur at this stage, the submitter will need to correct and resubmit the entire electronic file to Availity.

 

Immediate Batch Response (IBR) — This report acknowledges accepted claims and identifies claim edits due to HIPAA and business edits. The report also includes claim counts and charges for the electronic file. Availity creates this file prior to routing accepted claims to the adjudication systems.

• Action required for claims with edits: Rejected claims require resubmission within timely filing guidelines and will not advance to the adjudication system that would display Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. Not applicable to denied claims.

 

Delayed Payer Report (DPR) — This report is currently only returned for the Medicaid or Medicare lines of business and contains second-level editing from the adjudication system after Availity has routed claims that passed on the IBR report.

• Action required for claims with edits: Rejected claims would need to be resubmitted and will not display on Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice and paper Explanation of Payment.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative call Availity Client Services with any questions at 1-800-AVAILITY (282-4548), or call Provider Services:

• Medicaid: 1-800-450-8753
• Medicare Advantage: Call the number on the back of members’ ID cards

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire.

 

NYE-NU-0338-21 August 2021

519370MUPENMUB

 

On August 21, 2020, November 20, 2020, and June 24, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Insert plan. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

 

Effective date	Document number	Clinical Criteria title	New or revised
November 3, 2021	*ING-CC-0201	Rybrevant (amivantamab-vmjm)	New
November 3, 2021	*ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
November 3, 2021	*ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
November 3, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
November 3, 2021	ING-CC-0124	Keytruda (pembrolizumab)	Revised
November 3, 2021	*ING-CC-0102	GnRH Analogs for Oncologic Indications	Revised
November 3, 2021	ING-CC-0076	Nulojix (belatacept)	Revised
November 3, 2021	*ING-CC-0077	Palynziq (pegvaliase-pqpz)	Revised
November 3, 2021	ING-CC-0067	Prostacyclin Infusion and Inhalation Therapy	Revised
November 3, 2021	ING-CC-0194	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	Revised

 

EBSCRNU-0189-21 September 2021

In 2022, Empire BlueCross BlueShield (Empire) will be providing members with a new tool to develop an advance medical directive for many of its DSNP Medicare Advantage plans. Empire has partnered with MyDirectives,* a leader in the industry for electronic advance directives. Information on the service will be provided to members via their Annual Notice of Change (ANOC), Evidence of Coverage (EOC), and Benefit Summaries.

 

To get started with the Advance Directives program, members will visit the Empire member website and under the Benefits tab access a link for the Advance Directives program. Selecting this link will take the member to MyDirectives, where they can create a MyDirectives account or link an account if they already use MyDirectives.

 

MyDirectives has an easy-to-use guide that takes members through a series of questions around their care preferences, establishing of healthcare agents (medical powers of attorney), sharing of information, and more. If they already have a written advance directive, the software allows members to upload copies of their current directive, making it easier to store and share when necessary.

 

Physicians and hospitals can access a member’s advance directive via healthcare exchanges such as eHealth Exchange, Carequality, and CommonWell Health Alliance.

 

The benefit and associated links will be live as of the new plan year. We encourage you to speak to your members about the value of an establishing an advance directive and support members as they go through the process.

 

* MyDirectives is an independent company providing electronic advance directives services on behalf of Empire BlueCross BlueShield.

 

EBSCRNU-0197-21 September 2021

 

Please continue to read news and updates at empireblue.com/medicareprovider for the latest Medicare Advantage information, including:

• Empire BlueCross BlueShield expands specialty pharmacy precertification list