 Provider News New YorkNovember 2022 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (Empire) allows participating physicians to perform select laboratory services in their office, according to Empire’s Physician Office Laboratory (POL) Listing. Empire continuously reviews the POL list to ensure that laboratory services appropriate for the physician’s office are included.
As a result, Empire’s POL listing has been updated and is effective February 1, 2023. As a reminder, Empire’s POL list can be found online at empireblue.com/provider > Provider Forms & Guides > Physician Office Lab (POL) List and is also attached.
Empire members must be referred to a participating laboratory for any lab services not included on the POL list. Claims submitted to Empire for physician office laboratory services not on the POL list will be denied and members cannot be balance billed. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Providers currently submit prior authorization (PA) requests to AIM Specialty Health ®* (AIM) for outpatient diagnostic imaging services. These PA requests are often reviewed based on provider attestation of certain requirements.
As part of our ongoing quality improvement efforts, we want you to know that some review requests may require documentation to substantiate the attestations that support the clinical appropriateness of the request. This documentation can be uploaded during the intake process.
When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the PA review attestations.
If the PA request results in a denial as not medically necessary, providers may participate in a peer-to-peer discussion with an AIM physician reviewer and/or submit such documentation for a re-review within the allotted timeframes.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. A recent study indicated that several post office boxes are no longer being utilized by providers. To streamline our internal mail processing, we are retiring these post office boxes and utilizing post office boxes currently being used.
While we have not received any incoming mail from these retiring post office boxes in the last 12 months, should mail be received, it will be forwarded for a 12-month period. This change is effective immediately.
No action is required, this is an informational notification.
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Retiring PO Box number
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Replacement PO Box number
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PO Box 5075, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5077, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5020, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5076, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5070, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5071, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5078, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5047, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5072, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5068, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5009, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5011, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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PO Box 5069, Middletown NY 10940
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PO Box 5063, Middletown NY 10940
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Consider using Availity.com when sharing information with us. Digital submissions are faster and more efficient than mailing. To register with Availity Essentials, use this link.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting them to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We’re phasing in clear, concise and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line has denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. We’re starting with those claims or claim lines that have caused the most confusion based on your feedback. If new denial reasons are added, the descriptions will be expanded, as well.
Accessing Claims Status
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Working together to streamline processes through technology is a collaborative effort. We appreciate your feedback as we continue to improve to meet your expectations. The enhancements we’ve made to the Availity* Essentials Authorization application make it faster, easier, and more efficient to submit digital authorizations for Empire BlueCross BlueShield members.
View attachments for authorizations submitted – now you can view the attachments you’ve submitted to support your authorization in the Availity Essentials Authorization application.
Servicing and Rendering provider – we’ve enhanced the Availity Essentials Authorization application to enable a group option when selecting the servicing and rendering provider
View correspondence – Access status and decision letters right from the Authorization application Dashboard. Letters can also be downloaded or printed if needed.
Enhanced provider status – Out-of-Network and In-Network provider status has been enhanced to return fewer errors associated with provider status
Expanded search – Search rendering and serving provider by NPI and ZIP code for quicker results returned
Procedure code enhancement – Add the procedure code on an outpatient authorization for more accurate submission
Case update features – Now you can update your authorization right from your authorization Dashboard
Training sessions on the Availity Essentials Authorization application are still available
Whether you prefer live training webcasts, on-demand webinar recordings or a resource guide, we have everything you need to learn more about the Availity Essentials Authorization application and how to make the most of the application. Use this link to access the training option best for you.
Next live webcast: Wednesday, November 9, 2022, at 11 a.m. Eastern. Register here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. When submitting claims through the Electronic Data Interchange (EDI) you indicate supporting documentation is coming by completing the PWK segment on the claim. The PWK segment indicator tells us that you will be submitting supporting documentation for the claim and it also ensures the documents are attached correctly to the claim. You upload the supporting documents through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for Empire BlueCross BlueShield claims
The sooner we receive the attachments you indicated we will receive, the faster the claim can begin to process for payment. To meet this expectation, the Attachments Dashboard will begin a 7 calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Submitting Empire BlueCross BlueShield claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the
CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. New learnings added to the Provider Learning Hub
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from empireblue.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Commercial, Medicaid, and Medicare Advantage programs from Empire.
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered by Empire.
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com,
FAQ
How does Empire retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Empire secure network drives.
Why does Empire need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
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 https://www.empireblue.com.
Note: These updates may not apply to all ASO 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®), please visit www.fepblue.org > Policies & Guidelines.
Medical Policy updates
Revised medical policy effective August 18, 2022
The following policy was revised to expand medical necessity indications or criteria:
- MED.00129 Gene Therapy for Spinal Muscular Atrophy
Revised medical policy effective September 7, 2022
The following policy was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- MED.00129 Gene Therapy for Spinal Muscular Atrophy
New medical policy effective September 28, 2022
The following policy is new:
- MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy
Revised medical policy effective September 28, 2022
The following policy was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
Revised medical policies effective September 28, 2022
The following policies were updated with new CPT®/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
- GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
- GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- LAB.00015 Detection of Circulating Tumor Cells
- LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease
- MED.00098 Hyperoxemic Reperfusion Therapy
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00120 Internal Rib Fixation Systems
Archived medical policy effective October 5, 2022
The following policy has been archived:
- GENE.00034 SensiGene® Fetal RhD Genotyping Test
Revised medical policy effective October 5, 2022
The following policy was revised to expand medical necessity indications or criteria:
- SURG.00119 Endobronchial Valve Devices
Revised medical policies effective October 5, 2022
The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
- DME.00025 Self-Operated Spinal Unloading Devices
- DME.00041 Ultrasonic Diathermy Devices
- DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
- GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site
- GENE.00020 Gene Expression Profile Tests for Multiple Myeloma
- GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies
- GENE.00058 TruGraf Blood Gene Expression Test for Transplant Monitoring
- LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00028 Serum Biomarker Tests for Multiple Sclerosis
- LAB.00029 Rupture of Membranes Testing in Pregnancy
- LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
- LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia
- LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
- MED.00055 Wearable Cardioverter Defibrillators
- MED.00082 Quantitative Sensory Testing
- MED.00089 Quantitative Muscle Testing Devices
- MED.00096 Low-Frequency Ultrasound Therapy for Wound Management
- MED.00103 Automated Evacuation of Meibomian Gland
- MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring System.
- OR-PR.00007 Microprocessor Controlled Knee-Ankle-Foot Orthosis
- RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
- RAD.00061 PET/MRI
- RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
- SURG.00008 Mechanized Spinal Distraction Therapy
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00077 Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
- SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
- SURG.00088 Coblation® Therapies for Musculoskeletal Conditions
- SURG.00092 Implanted Devices for Spinal Stenosis
- SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
- SURG.00107 Prostate Saturation Biopsy
- SURG.00114 Facet Joint Allograft Implants for Facet Disease
- SURG.00128 Implantable Left Atrial Hemodynamic Monitor
- SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
- SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves
- SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- SURG.00153 Cardiac Contractility Modulation Therapy
- SURG.00156 Implanted Artificial Iris Devices
- SURG.00157 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
New medical policy effective October 15, 2022
The following policy is new:
- MED.00140 Gene Therapy for Beta Thalassemia
Revised medical policies effective October 15, 2022
The following policies were revised to expand medical necessity indications or criteria:
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
Revised medical policies effective October 15, 2022
The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- LAB.00011 Selected Protein Biomarker Algorithmic Assays
- SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
Revised medical policies effective October 15, 2022
The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:
- RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
- TRANS.00038 Thymus Tissue Transplantation
Archived medical policy effective November 6, 2022
The following policy has been archived and has been replaced by AIM guidelines:
- SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
New medical policies effective February 1, 2023
The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- DME.00050 Remote Devices for Intermittent Monitoring of Intraocular Pressure
- LAB.00049 Artificial Intelligence-Based Software for Prostate Cancer Detection
Revised medical policy effective February 1, 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:
- DME.00044 Robotic Arm Assistive Devices
New medical policies effective February 4, 2023
The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- DME.00049 External Upper Limb Stimulation for the Treatment of Tremors
- MED.00141 High-volume Colonic Irrigation
- TRANS.00040 Hand Transplantation
Revised medical policy effective February 4, 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.00079 Nasal Valve Repair
Revised medical policy effective February 11, 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.00121 Transcatheter Heart Valve Procedures
Clinical Guideline updates
Revised clinical guideline effective August 24, 2022
The following adopted guideline was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- CG-MED-68 Therapeutic Apheresis
Revised clinical guidelines effective September 28, 2022
The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:
- CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
- CG-MED-68 Therapeutic Apheresis
- CG-SURG-97 Cardioverter Defibrillators
Unadopted clinical guideline effective October 1, 2022
The criteria in the following guideline will no longer be applied:
- CG-SURG-96 Intraocular Telescope
Revised clinical guideline effective October 5, 2022
The following adopted guideline was revised to expand medical necessity indications or criteria:
- CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
Revised clinical guidelines effective October 5, 2022
The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- CG-DME-10 Durable Medical Equipment
- CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
- CG-DME-44 Electric Tumor Treatment Field (TTF)
- CG-MED-55 Site of Care: Advanced Radiologic Imaging
- CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
- CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
- CG-MED-69 Inhaled Nitric Oxide
- CG-MED-83 Site of Care: Specialty Pharmaceuticals
- CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
- CG-REHAB-08 Private Duty Nursing in the Home Setting
- CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
- CG-SURG-52 Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services
- CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
- CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Revised clinical guidelines effective February 1, 2023
The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary:
- CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-GENE-13 Genetic Testing for Inherited Diseases
Revised clinical guidelines effective February 11, 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-DME-31 Powered Wheeled Mobility Devices
NYBCBS-CM-009373-22 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Commercial, Medicaid, and Medicare Advantage programs from Empire.
Effective November 6, 2022, Empire will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
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 https://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 Availity* at availity.com.
For questions related to guidelines, 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. Material Adverse Change (MAC)
In the July edition of Provider News, we announced a new Place of Service - Facility reimbursement policy indicating that evaluation & management (E/M) services and other professional services must be billed on a CMS-1500 claim form and are not reimbursable when billed on a UB-04 claim form (excluding E/M services rendered in an emergency room or urgent care and billed with ER revenue codes).
It has come to our attention that some of the preventive counseling CPT® codes mentioned in the July article were listed incorrectly. The correct preventive counseling CPT codes are 99401–99404, 99411, and 99412, and are not reimbursable when billed in an outpatient setting of a facility effective with dates of service on or after February 1, 2023.
Please note, however, that the revenue codes 960-983 and the E/M services noted in the July edition were listed correctly in the new Place of Service — Facility reimbursement policy effective with dates of service on or after October 1, 2022.
For specific policy details, visit the reimbursement policy page on empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
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 Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), 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.
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
Prior authorization updates
Effective for dates of service on and after February 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 prior authorization updates.
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Clinical Criteria
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0002*
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Fylnetra (pegfilgrastim-pbbk)
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J3590
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ING-CC-0002*
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Rolvedon (eflapegrastim-xnst)
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C9399, J3490, J3590
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ING-CC-0002*
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Stimufend (pegfilgrastim-fpgk)
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C9399, J3490, J3590
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ING-CC-0072
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Cimerli (ranibizumab-cqrn)
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J3590
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ING-CC-0220
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Xenpozyme (olipudase alfa)
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C9399, J3490, J3590
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ING-CC-0221
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Spevigo (spesolimab-sbzo)
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C9399, J3490, J3590
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* Oncology use is managed by AIM.
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 February 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.
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Clinical Criteria
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Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0065
|
Advate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Adynovate (factor vii)
|
J7207
|
|
ING-CC-0065
|
Afstyla (antihemophilic factor (recombinant) single chain))
|
J7210
|
|
ING-CC-0065
|
Alphanate (antihemophilic factor viii)
|
J7186
|
|
ING-CC-0065
|
Eloctate (recombinant antihemophilic factor)
|
J7205
|
|
ING-CC-0065
|
Esperoct (factor viii recombinant, glycopegylated)
|
J7204
|
|
ING-CC-0065
|
factor viii, anti-hemophilic factor (porcine)
|
J7191
|
|
ING-CC-0065
|
Hemlibra (emicizumab-kxwh)
|
J7170
|
|
ING-CC-0065
|
Hemofil M ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Humate-P (antihemophilic factor viii)
|
J7187
|
|
ING-CC-0065
|
Jivi (factor viii, recombinant, pegylated-aucl)
|
J7208
|
|
ING-CC-0065
|
Koate DVI ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Kogenate-FS (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Kovaltry (factor viii (antihemophilic factor, recombinant))
|
J7211
|
|
ING-CC-0065
|
Novoeight (factor viii (antihemophilic factor, recombinant))
|
J7182
|
|
ING-CC-0065
|
Nuwiq (factor viii (antihemophilic factor, recombinant))
|
J7209
|
|
ING-CC-0065
|
Obizur (antihemophilic factor viii (recombinant))
|
J7188
|
|
ING-CC-0065
|
Recombinate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Vonvendi (von willebrand factor)
|
J7179
|
|
ING-CC-0065
|
Wilate (antihemophilic factor viii)
|
J7183
|
|
ING-CC-0065
|
Xyntha (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0065
|
Xyntha Solofus (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0148
|
AlphaNine SD (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Alprolix (recombinant coagulation factor ix)
|
J7201
|
|
ING-CC-0148
|
Benefix (factor ix recombinant)
|
J7195
|
|
ING-CC-0148
|
Idelvion (factor ix)
|
J7202
|
|
ING-CC-0148
|
Ixinity (factor ix)
|
J7195
|
|
ING-CC-0148
|
Mononine (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Profilnine SD (factor ix complex human)
|
J7194
|
|
ING-CC-0148
|
Rebinyn (glycopegylated)
|
J7203
|
|
ING-CC-0148
|
Rixubis (factor ix recombinant)
|
J7200
|
|
ING-CC-0149
|
Coagadex (factor x)
|
J7175
|
|
ING-CC-0149
|
Corifact (factor xiii concentrate (human))
|
J7180
|
|
ING-CC-0149
|
Feiba (anti-inhibitor coagulant complex)
|
J7198
|
|
ING-CC-0149
|
Fibryga (human fibrinogen)
|
J7177
|
|
ING-CC-0149
|
NovoSeven RT (factor viia recombinant)
|
J7189
|
|
ING-CC-0149
|
RiaSTAP (fibrinogen concentrate)
|
J7178
|
|
ING-CC-0149
|
Sevenfact (factor vlla recombinant)
|
J7212
|
|
ING-CC-0149
|
Tretten (coagulation factor xiii a-subunit (recombinant))
|
J7181
|
Step therapy updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Clinical criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Fylnetra
|
J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Rolvedon
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Stimufend
|
C9399, J3490, J3590
|
|
ING-CC-0002
|
Preferred
|
Neulasta
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Neulasta OnPro
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
ING-CC-0002
|
Non-preferred
|
Nyvepria
|
Q5122
|
|
ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
*Oncology use is managed by AIM
This is a courtesy notice that there is a non-material change in the clinical criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).
Quantity limit updates
Effective for dates of service on and after February 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)
|
|
ING-CC-0017
|
Xiaflex (collagenase clostridium histolyticum)
|
J0775
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0182
|
Feraheme (ferumoxytol)
|
Q0138
|
|
ING-CC-0182
|
Ferrlecit (ferric gluconate)
|
J2916
|
|
ING-CC-0182
|
Infed (iron dextran)
|
J1750
|
|
ING-CC-0182
|
Injectafer (ferric injection)
|
J1439
|
|
ING-CC-0182
|
Monoferric (ferric derisomaltose)
|
J1437
|
|
ING-CC-0182
|
Venofer (iron sucrose)
|
J1756
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. According to the American Medical Association (AMA) Current Procedural Terminology ® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after December 1, 2022, Empire BlueCross BlueShield HealthPlus will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the claims payment dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M code.
If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website (https://providerpublic.empireblue.com) for up-to-date contact information or call Provider Services at 800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the members’ coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision-makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website. You can request a free copy of our UM criteria from Provider Services at 800-450-8753. Providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the number listed below. To access UM criteria online, visit: anthembluecross.com/provider/policies/clinical-guidelines. We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secure voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues. You can submit precertification requests by: - Using the Availity Essentials Authorization application. Log in to Availity Essentials and select Patient Registration > Authorizations and Referrals. You can also access information previously mailed or faxed anytime in Availity Essentials.
- Faxing to 800-964-3627.
- Calling us at 800-450-8753.
Have questions about utilization decisions or the UM process?Call Provider Services at 800-450-8753, Monday through Friday, from 8:30 a.m. to 5:30 p.m. ET. or use Chat with Payer from Payer Spaces on Availity Essentials. * Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus. Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NYBCBS-CD-003874-22-CPN3786 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. When it comes to diabetes, improving the standard of patient care and patient outcomes is grounded in wellness: prevention, regularly scheduled screening, and effective care. Genetics, lifestyle, and medication are a confluence of factors, which impact metabolic health.1 For patients diagnosed with schizophrenia or bipolar disorder who are prescribed an antipsychotic medication, the prevalence of developing diabetes is higher than that of the general population. If you are seeing an Empire BlueCross BlueShield HealthPlus member who is prescribed antipsychotic medication, specific protocols are required for a proper treatment plan. Based on best practice, members prescribed an antipsychotic should be administered a glucose test or an HbA1c test at least once a year to screen for diabetes. If screening indicates the member is diabetic, the member should be monitored for diabetes. In turn, patients being monitored for diabetes should receive an HbA1c test and an LDL-C test at least once a year. As the literature often states, a small change has a huge impact on managing diabetes or preventing it all together.2 Screen, test, educate, and be the provider providing timely and effective diabetes care.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Alcohol use disorders (AUD) often coexist with, contribute to, or result from many different psychiatric disorders.1 Because AUD can mimic and complicate many mental health disorders, AUD leads to challenges in diagnoses for psychiatric complaints.
Heavy alcohol use directly affects brain function and may manifest as a broad range of psychiatric symptoms. Common mental health symptoms of AUD include depression and anxiety.
In addition, patients diagnosed with mental health disorders are more likely to use a high amount of mental health services, have difficulties decreasing alcohol consumption, and struggle with suicidal ideation or attempts.
Common co-occurring mental health conditions include depressive disorders, anxiety, schizophrenia, and bipolar disorders.
Depressive disorders:2
AUD and depressive disorders are among the most prevalent co-occuring disorders. Depressive disorders are the most common comorbid mental health conditions with AUD. People with AUD are 2 to 3 times more likely to have depression. People with alcohol dependence are more likely to have a depressive disorder than those with alcohol abuse.
Co-occurring AUD and depressive disorders disproportionately affect women, as these disorders are two times more likely to occur in women than in men. Racial and ethnic minorities also encounter systemic disadvantages. For instance, Black and Latino people are significantly less likely to receive integrated mental health and substance use treatment than other races and ethnicities.
Research suggests that AUD is equally as likely to precede depression as well as for depression to precede AUD. In addition, having one increases the risk of having the other. Though the etiology of these disorders is not fully known, studies have identified some evidence of genetic predisposition or dysfunction in reward and stress systems of the brain.
Anxiety:3
Up to half of patients receiving treatment for AUD meet the criteria for one or more anxiety disorders. Data shows that patients with anxiety disorders have poorer outcomes in treatment for alcohol use. Conventional treatment for anxiety (antidepressants and behavioral therapy) do not appear to reduce AUD. This suggests that co-occurring anxiety and AUD benefits from being treated separately but simultaneously.
In addition, patients with an anxiety disorder or AUD experience an increased risk in developing the other disorder. Trauma, chronic stress, and other inheritable traits are associated with the dysfunction in stress‑response systems present in AUD and anxiety disorders.
Schizophrenia:4
The prevalence of schizophrenia is about 1% of the population; however, patients with schizophrenia are at a three times greater risk for AUD. Between 25% to 36% of patients with schizophrenia meet the criteria for AUD. Schizophrenia has a strong genetic risk factor, and a large genome-wide study revealed a significant genetic correlation between schizophrenia and AUD.
There are several theories as to why AUD is so highly prevalent in patients with schizophrenia:
- A combination of neurobiological vulnerability (genetic risk) and environmental vulnerability (poverty, homelessness, trauma, etc.)
- The concept of self-medication, suggesting people with schizophrenia turn to alcohol for relief from their psychiatric symptoms
- Similar to depressive disorders, the hypothesis that both schizophrenia and AUD are related to a dysregulation of the reward system in the brain
Bipolar disorder:5
Bipolar disorder is the most likely psychiatric disorder to have a co‑occurring condition with a substance use disorder (SUD). Estimates for a lifetime co‑occurring bipolar disorder and AUD is between 40% to 70%. These co-occurring disorders are most common in women.
Bipolar disorder occurs in between 1.5% to 5% of the population. Like schizophrenia, bipolar disorder has a shared genetic predisposition with AUD. Heavy alcohol use worsens symptoms of bipolar disorder and can trigger episodes of mania and depression. Conversely, these episodes can lead to increased alcohol consumption. Treatment for bipolar disorder often assists in treatment for co‑occurring AUD. Mood stabilizers used to treat bipolar disorder have been shown to reduce alcohol cravings in patients with bipolar disorder.
Alcohol (and other substances) are likely triggers for the onset of bipolar disorders. In one study, substance use preceded 60% of first manic episodes.6 In juvenile cases, bipolar onset early in life is correlated with AUD development as an adult.
What if I need assistance?
If you need assistance connecting your patients to mental health or AUD treatment, contact Empire BlueCross BlueShield HealthPlus Provider Services at 800-450-8753.
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 from Empire.
Effective January 1, 2023, Empire BlueCross BlueShield Healthplus will be adding behavioral health benefits as part of New York State’s carve-in for Medicaid Advantage Plus members. We are offering webinars to help you understand the upcoming changes for the behavioral health carve-in of Medicaid Advantage Plus (MAP). The webinars will cover: MAP transition; case management and care coordination support; benefits, authorization, and utilization management overview; and claims. Details and dates of trainings will be made available in next month's newsletter.
November 15th 9:30 a.m. Register
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. This communication applies to the Medicaid and Medicare Advantage programs from Empire.
Effective January 1, 2023, Empire BlueCross BlueShield Healthplus will be adding behavioral health benefits as part of New York State’s carve-in for Medicaid Advantage Plus members. We are offering webinars to help you understand the upcoming changes for the behavioral health carve-in of Medicaid Advantage Plus (MAP). The webinars will cover: MAP transition; case management and care coordination support; benefits, authorization, and utilization management overview; and claims. Details and dates of trainings will be made available in next month's newsletter.
November 15th 9:30 a.m. Register
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |