Effective April 1, 2019, Empire will update its HMO, EPO, PPO, and Indemnity fee schedules.  

Although this update will result in an overall net increase of our physician network fees, the actual impact to any particular physician will depend on the codes most frequently billed by that physician.

The complete updated fee schedule will be available on our Physician Online Services at www.empireblue.com upon their effective date of April 1, 2019.

Continuing to build on the initial launch of the new public provider pages, Empire recently released a brand new, redesigned landing page for Provider Resources. The most recent release also includes a new Communications page with a clear and concise access point for Newsletters and eUpdates, as pictured below.

This October, empireblue.com will be introducing exciting changes to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for manuals and an improved, streamlined experience for Reimbursement Policies.

We will continue to keep you informed on upcoming changes to the public provider site as we progress toward streamlining our web platform and other business processes.

In the October 2017 issue of Network Update, Empire informed you about our mobile app called Empire Anywhere that allows members to manage their benefits on their smart phones, including electronic copies of their ID cards.  We want to ensure a member’s request for electronic ID card meets a provider’s office needs.  If presented with an electronic card, you may still obtain a copy of the ID card for your records.

Since fall 2017, we began allowing members the option to choose electronic cards only.  If the member chooses this option, he/she will not receive a hard copy card. Members will continue to have the option of selecting a hard copy card if that is their preference.

Provider options for obtaining a copy of an electronic Member ID card:

• Email or Fax:
  • Members can email/fax the card from his/her phone. When members are viewing their ID Card on their phone, they will select the Share icon  and forward the card via email or fax.

• Online:
  • Providers also have the option to view Empire Member ID Cards online (and print if needed) from the Availity Web Portal when conducting an Eligibility and Benefits (E&B) Inquiry. From the E&B Results page, select the blue button titled View Member ID Card. 

Note: as with all E&B Inquiries on Availity, providers must have the member ID number (including the three-character prefix). 

Members are still required to have a copy of their card in one format or another, whether hard copy or electronic, in order for services to be rendered.  See our Quick Reference Guide, for further details.

Are you looking for innovative ways to improve your patients’ experiences and earn continuing medical education credits?

Numerous studies have shown that a patient’s primary health care experience and, to some extent, their health care outcomes are largely dependent upon health care provider and patient interactions. Empire offers a new online learning course, What Matters Most: Improving the Patient Experience, to offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide and is acceptable for up to one prescribed continuing medical education credit by the American Academy of Family Physicians.

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices.

Did you know?

Substantial evidence points to a positive association between patient experience and health outcomes.

• Patients with chronic conditions, such as diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.
• Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.

How will this benefit you and your office staff? 

You’ll learn tips and techniques to:

• Improve communication skills.
• Build patient trust and commitment.
• Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey.

The course can be accessed at www.patientexptraining.com using your smartphone, tablet or computer.

Like you, Empire is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

The Special Investigations Unit (SIU) is tasked to conduct investigations involving allegations of fraud, waste and abuse, to work with our providers to resolve billing practice issues in order to reduce or eliminate future payment issues, and, where appropriate, to recover overpayments.

As part of Empire’s role to safeguard our members and provide relevant information to providers we are relaying the following recent Food and Drug Administration (FDA) Warning Letters:  

Estring - On June 19, 2018, the Food and Drug Administration issued a letter of warning to Pfizer for "false or misleading" promotional materials related to ESTRING® (estradiol vaginal ring).  According to the FDA the posted “… video is especially concerning from a public health perspective because it fails to include any risk information about Estring, which is a drug that bears a boxed warning due to several serious, life-threatening risks, including endometrial cancer, breast cancer, and cardiovascular disorders, as well as numerous contraindications and warnings. The video thus creates a misleading impression about the safety and efficacy of Estring”.

Xtampza – On February 9, 2018, the Food and Drug Administration issued a letter of warning to Collegium Pharmaceuticals for publicly providing false or misleading representations regarding Xtampza (oxycodone) ER because it “fails to adequately communicate information about the serious risks associated with Xtampza ER use”.

Click the links belwo for further details regarding these Warning Letters from the FDA .

• Estring
• Xtampza

We have completed the HEDIS data collection for 2018 and want to thank all of our provider offices and their staff who assisted us.  Your collaboration in this process allows us to strive for the best HEDIS results possible.

This is the 7th year for our incentive program to acknowledge some of our providers who either responded in a timely manner or went “Above & Beyond” to help make our HEDIS data collection successful.   Any practices that responded within 5 business days of our initial request or who went out of their way by taking additional steps to help us with data collection were entered in a drawing to receive a gift. We are pleased to announce that our incentive winners are as follows:

NY Winners - HEDIS Drawing

• Wynantskill Family Medical Practice
• Aaron S. Greenberg, MD
• All Care Family Practice
• Joseph Mackey, MD
• Sovereign Medical Group, LLC

NY Winners – Above & Beyond

• San S. Shih, MD
• St. Peter’s Health Partners
• ProHEALTH Care Associates

Our HEDIS results reflect the care you provide to our members. Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.

An overview of our HEDIS rates will be published in the December provider newsletter. In addition more information on HEDIS can be found by visiting the provider portal at empireblue.com/provider/ Select “Find Resources in New York” > Provider Home > > Health and Wellness > Quality Improvement and Standards > HEDIS Information.

Thanks again to all of our provider offices and their staff for assisting us in collecting HEDIS data. We look forward to working with you next HEDIS season!

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

In our ongoing efforts to encourage medical and behavioral health integration, Empire continues to promote early identification and intervention of behavioral health issues through primary care.  Empire currently reimburses for screening and assessment for behavioral health and substance use through billing the following codes:

• G0396 /99408 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes 
• G0397 / 99409 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes
• G0442 - Annual alcohol misuse screening, 15 minutes £ G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0444 - Annual depression screening, 15 minutes

Empire also supports behavioral counseling for specific chronic conditions while in the primary care office.  These services include:

• G0446 - Annual, face-to-face intensive behavioral therapy for cardiovascular disease, 15 minutes
• G0447 - Face-to-face behavioral counseling for obesity, 15 minutes
• G0473 - Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

In addition, Empire reimburses for the psychiatric collaborative care codes; procedure codes 99492, 99493, 99494 are used to report these services.  These codes are reportable by primary care for their collaboration with a qualified behavioral health provider, such as a Psychiatrist, Licensed Clinical Social Worker, etc..  Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a BH specialist.  The American Psychiatric Association (APA) has created a training program for primary care on the collaborative care model and the use of these codes.  It can be found at APA Training Module. 

Empire has partnered with Availity to operate and service the entry point for all EDI submissions to Empire, otherwise known as the EDI Gateway.

Who is Availity?

Most of you know Availity as web portal or claims clearinghouse, but they are much more.  Availity is also an intelligent EDI Gateway for multiple vendors and will be the EDI connection for all Empire Inc. and its affiliates.

If you currently use a clearinghouse, billing company or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Empire.

How are you submitting EDI transactions today?

• If you currently transmit your EDI Submissions using a clearinghouse or Billing Company, you should contact your clearinghouse to confirm your EDI submission path has not changed. 
• If you are notified of any potential impacts with connectivity, workflow or financial, please know there is no cost alternate submission options available with Availity.
• If you currently submit directly to Empire and already have an Availity login for the portal, you can use that same login for your EDI services.
• Please visit https://apps.availity.com/web/welcome/#/Empire to learn more.

How can you directly transmit EDI submission to Availity?

Below are the different ways you can submit direct EDI transactions to Availity:

• Submit transaction files through FTP - If you work with a practice management system, health information system, or other automated system that supports an FTP connection, you can securely upload EDI transactions to the Availity FTP site where they are automatically picked up by Availity and submitted to Empire
• Submit transaction files through the Availity Portal - If you have batch files of EDI transactions that you need to process and you choose not to use the Availity FTP site, you can manually upload the batch files through the Availity Portal.
• Submit transactions through manual data entry in the Availity Portal – The Availity Portal makes it easy to submit transactions, such as eligibility and benefits inquiries or claims, by entering data into our user-friendly web forms.

What are your next steps?

• It may take time to work with your clearinghouse or billing company, so please take action now to help ensure continuity of your EDI transactions.

• If you choose to submit direct, we recommend that you register with Availity for your EDI transmissions and begin migrating your volume by the end of  2018 by visiting this URL- https://apps.availity.com/web/welcome/#/anthem
• The EDI transacations include the 837, 835 and 27X (eligibility and claim status).
• Availity will be working directly with your Clearinghouse, Billing Companies or your organization if you choose to submit directly.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-Availity (1-800-282-4548) Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time. 

Great news! Empire, Inc. and our affiliates now use Availity as our designated EDI service. If you currently use a clearinghouse, billing company, or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Empire.

Check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session. During this fast paced hour, learn how to:

• Understand Availity’s EDI Gateway and Clearinghouse workflow for 837, 270/271, 276/277, and 835 transactions.
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences, manage your FTP account, and more.
• Enroll for and manage 835 ERA delivery with Availity.
• Access and navigate the Availity EDI Guide.
• and more…..

Upcoming Sessions

Currently scheduled upcoming sessions include:

• October 29, 2018, 1:00 p.m. – 2:00 p.m. ET
• November 7, 2018, 11:00 a.m. – 12:00 p.m. ET

Enroll

1. Log in to the Availity Portal.
2. Select Help and Training > Get Trained.
3. In the Availity Learning Center (ALC) Catalog, select Sessions.
4. Scroll Your Calendar to find and enroll for a live session.

Can’t make it?

We’ve got you covered with a recording of a previous live session. In the ALC, search the Catalog by keyword (song) and enroll for the on-demand option.

Need Help?

Email training@availity.com if you have issues enrolling for a live webinar.

Extension for Community Healthcare Outcomes (ECHO)

People are dying of opioid addiction. With the ECHO opioid addiction treatment, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website.

Benefits of participating include:

• Addiction treatment training.
• Free continuing education credits.
• Opportunity to receive expert input on your (de-identified) patient cases.
• Access to a virtual learning community for treatment guidelines, tools and patient resources.
• Opportunity to ask questions and get a variety of support from specialists.

Quality Medication-Assisted Therapy (MAT)

To help ensure members have access to comprehensive evidence-based care, [BRAND] is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with buprenorphine or, in some plans, methadone maintenance treatment in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

For more information

For more information about best practices for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.

You can also contact Jennifer Tripp by email at jennifer.tripp@Empire.com for more information about the ECHO and MAT programs.

The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for non-grandfathered policies. The appropriate use of modifier 33 will reduce claim adjustments related to preventive services and your corresponding refunds to members.

Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.

Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.

The CPT® 2018 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”

Effective October 14, 2018, Empire will enforce the requirement to bill the correct modifier and HCPCS for services utilized.  Incorrect billing will be rejected and claims will be returned to the provider for correction and resubmittal.

Durable Medical Equipment (DME) may be purchased, rented or rented until the purchase price has been paid. 

Correct billing will allow member benefits to be applied correctly to include benefit accumulations for a member’s DME benefits.DME

These updates list the new and/or revised Empire medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service.  Previously processed claims will not be reprocessed as a result of the changes.  If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire.  Please include this update with your Provider Manual for future reference. 

Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.  Empire’s medical policies and clinical guidelines can be found at empireblue.com.

*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.

The AIM Genetic Testing program requires ordering providers to request medical necessity review of all genetic testing services for individual Medicare Advantage members.  Requesting this prior authorization will help ensure that the lab receives timely and accurate payment for these services.

Please submit genetic testing prior authorization requests to AIM through one of the following ways:

• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number at 800-714-0040, Monday–Friday, 7 a.m.–7p.m. CT.

For further questions regarding prior authorization requirements, please contact the Provider Services number on the back of your patient’s ID card.

Effective January 1, 2019, Empire will transition its Medicare back pain management and cardiology programs from OrthoNet LLC to AIM Specialty Health® (AIM), a specialty health benefits company. Empire has an existing relationship with AIM in the administration of other medical management programs.  Additional information will be available at Important Medicare Advantage Updates at empireblue.com/medicareprovider.

The Centers for Medicare & Medicaid Services has increased its emphasis on the appropriate use of statins among Medicare Advantage beneficiaries diagnosed with diabetes and cardiovascular disease. Please evaluate whether your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

The 2013 American College of Cardiology and the American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events. High-intensity statin therapy is recommended if the patient has an estimated 10-year ASCVD risk ≥7.5 percent. For males 21-75 and females 40-75 years of age with clinical ASCVD, high-intensity statin therapy is recommended unless contraindicated. These guidelines recommend statin therapy in these scenarios regardless of what patient LDL values are.  Please evaluate if your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

Formulary agents are listed below:

*Rosuvastatin (Crestor) is a preferred brand medication on the Medicare formulary. 

**Available for a $0 co-pay for most plans in 2018

Per guidance established by the Comprehensive Addiction and Recovery Act of 2016, the Centers for Medicare & Medicaid Services has established provisions to develop a pharmacy and prescriber home program for opioid medications.   Beginning January 1, 2019, Empire will work with beneficiaries and providers to help to reduce the risk of opioid dependency by streamlining access to opioid medications.  If a beneficiary is exhibiting at-risk opioid medication utilization, the plan sponsor will work with the beneficiary and provider to select a pharmacy home and prescriber home for the beneficiary’s opioid medications.   At risk is defined by CMS as

1. Cumulative Morphine Milligram Equivalent (MME) > 90mg per day
2. Opioid prescribers > than three and opioid dispensing pharmacies > than three
3. Or Opioid prescribers > than five regardless the number of pharmacies

• Cancer, LTC and Hospice are exempt
• Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.
• Plan sponsors will request agreement from the provider selected as the home.
• At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.
• Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.
• Beneficiaries retain the right to request a coverage determination and may choose to change their Home pharmacy or prescriber at any time.

Effective January 1, 2019, Empire BlueCross (EBC) and Empire BlueCross BlueShield (EBCBS) group-sponsored Medicare Advantage plan members will receive new ID Cards.   Members will be assigned a new alpha prefix and group number.  New ID cards will be mailed to members in December 2018.

Beginning January 1, 2019, EBC and EBCBS members enrolled in a group-sponsored HMO Medicare Advantage plan will have the alpha prefix of AAN.  EBC and EBCBS members enrolled in a group-sponsored PPO Medicare Advantage plan will have the alpha prefix of XLU.   

The provider services phone number is on the back of the member ID card. Providers should submit claims to their local Blue Cross and Blue Shield plan for processing.  

Please continue to check Important Medicare Advantage Updates at empireblue.com/medicareprovider for the latest Medicare Advantage information, including:

• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila  
• July Medicare Advantage reimbursement policy  
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  
• Inpatient Readmissions  
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective Sept. 1  

Empire BlueCross BlueShield HealthPlus (“Empire”) has partnered with Availity to become our designated EDI Gateway, effective January 1, 2019.

What does this mean to you as a provider?

All EDI submissions currently received are now available on Availity. Please note, there is no impact to provider participation statuses and no impact on how claims adjudicate.

Next steps

Contact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you — You can submit claims directly through Availity!

Register with Availity

If you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-282-4548, Monday to Friday, 8 a.m. to 7:30 p.m. Eastern time. 

Extension for Community Health Care Outcomes (ECHO)

People are dying of opioid addiction. With the medication assisted treatment, you can help save lives! Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website at https://echo.unm.edu.

Benefits of participating include:

• Addiction treatment training.
• Free continuing education credits.
• Opportunity to receive expert input on your (de-identified) patient cases.
• Access to a virtual learning community for treatment guidelines, tools and patient resources.
• Opportunity to ask questions and get a variety of support from specialists.

Quality Medication-Assisted Therapy (MAT)

To help ensure members have access to comprehensive evidence-based care, Empire is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with naltrexone, buprenorphine or, in some plans, methadone in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

For more information

For more information about what is considered best practice for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.

You can also contact Jennifer Tripp by email at jennifer.tripp@Empire.com for more information about the ECHO and MAT programs.

As part of our commitment to provide you with the latest clinical information and improve member outcomes, we have posted a vaginal birth after cesarean (VBAC) shared decision-making aid to our provider site. This tool has been reviewed and certified by the Washington Health Care Authority* and is available to aid in discussions with your patients regarding their treatment options.

If you have questions contact your local Provider Relations representative or call Provider Services at 1-800-450-8753.

* The Washington Health Care Authority is recognized as a certifying body by NCQA.

In our efforts to improve pregnancy outcomes, including the prevention of preterm birth, Empire BlueCross BlueShield HealthPlus previously communicated our endorsement of the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) guidelines on cervical length (CL) screening and progesterone treatment.

We continue to encourage you to obtain a CL measurement with your patient’s routine prenatal anatomic evaluation ultrasound. For claims submitted on or after January 1, 2019, if a vaginal approach is necessary in addition to an abdominal scan to obtain this measurement, the transvaginal ultrasound will be considered for a multiple procedure reduction.

When a routine anatomic evaluation ultrasound (76801, 76802, 76805, 76810) and a transvaginal ultrasound (76817) are billed on the same day by the same provider, the transvaginal ultrasound is considered a part of the multiple procedure payment reduction policy and will be paid at 60% of the applicable fee schedule, and the complete procedure will be paid at the full applicable fee schedule.

If you have questions contact your local Provider Relations representative or call Provider Services toll free at 1-800-450-8753.

Thank you for being a valued provider.

Effective December 1, 2018, prior authorization (PA) requirements will change for high-level, definitive drug testing(s). The high-level, definitive drug testing(s) will require PA for Empire BlueCross BlueShield HealthPlus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• G0482 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, gas chromatography/mass spectrometry (GC/MS) (any type, single or tandem) and liquid chromatography/mass spectrometry (LC/MS) (any type, single or tandem and excluding immunoassays; e.g., immunoassays [IA]; enzyme immunoassay [EIA]; enzyme-linked immunosorbent assay [ELISA]; enzyme multiplied immunoassay technique [EMIT]; fluorescence polarization immunoassay [FPIA]; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es) including metabolite(s) if performed.

• G0483 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays; e.g., IA; EIA; ELISA; EMIT; FPIA; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es) including metabolite(s) if performed.

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

Not all PA requirements are listed here. PA requirements are available on the provider website at www.empireblue.com/nymedicaiddoc > Prior Authorization & Claims > Prior Authorization Lookup Tool. Contracted and noncontracted providers may call Provider Services at 1-800-450-8753 for assistance with PA requirements.

Effective December 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drug Interferon beta-1a to be covered by Empire BlueCross BlueShield HealthPlus. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Interferon beta-1a — injection, 30 mcg (J1826)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-450-8753 for PA requirements.

Effective December 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drug Somatrem to be covered by Empire BlueCross BlueShield HealthPlus. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Somatrem — injection, 1 mg (J2940)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-450-8753 for PA requirements.

Medical Policies update

On January 25, 2018, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire). These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing.

The Medical Policies were made publicly available on our provider website on the effective date listed. To search for specific policies, visit http://www.empireblue.com/medicalpolicies/search.html.

Please note:

• Starting July 1, 2018, AIM Specialty Health® Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.
• For markets with carved-out pharmacy services, the applicable listings below are informational only.

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Clinical Utilization Management Guidelines update

On January 25, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines applicable to Empire. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

The clinical guidelines were made publicly available on our provider website on the effective date listed. To search for specific guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.

Please note:

• Starting July 1, 2018, AIM Specialty Health® Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.
• For markets with carved-out pharmacy services, the applicable listings below are informational only.

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

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

To search for specific policies or guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.

Medical Policies

On March 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).

Clinical UM Guidelines

On March 22, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

Note:

• Effective November 1, 2018, MCG Heath Care Guidelines will be used for reviews, to include the use of customizations to certain guidelines and:
  • o Inpatient and Surgical Care Guidelines.
  • o General Recovery Care Guidelines.
  • o Recovery Facility Care Guidelines.
  • o Chronic Care Guidelines.
  • o Behavioral Health Care Guidelines (NEW).
• Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.

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

To search for specific policies or guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.

Medical Policies

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).

Clinical UM Guidelines

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

(Metatags: medical policy, policy updates, member, benefits, claims, clinical guidelines,)