In the past Empire BlueCross BlueShield (“Empire”) sent you postcards to make you aware that the monthly Provider Newsletter was posted.  To be more ecologically aware we have made the decision to stop printing and mailing reminder postcards, effective immediately.

 

Provider News is posted the first day of each month – regardless of weekends or holidays.  You will receive an email notification when new editions are posted. These email notifications will inform you regarding which articles contain material adverse changes. Please be sure to add empireprovidercommunications@empireblue.com to your safe sender/recipient list and inform Empire of any updates to your email address.

You can download single articles or entire editions as a PDF and save to your computer – providing paperless convenience and easy access to pertinent information you may need.

 

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In September, Empire BlueCross BlueShield  (“Empire”) added new functionality to New York’s provider enrollment tool hosted on the Availity Portal to further automate and improve your online enrollment experience.

 

Who can use this new tool?

Professional providers, whose organizations do not have a credentialing delegation agreement with Empire. (Note: Providers who submit via roster or have delegated agreements will continue to use the process in place.)

 

What does the tool provide?

• Add new providers to an already existing group
• Apply and request a contract.
  After review, a contract can be sent back to you digitally for an electronic signature.  This eliminates the need for paper applications or paper contracts. 
  • Enroll a new group of providers.
  • Enroll as an individual/solo provider.
• A dashboard for real time status on the submitted applications.
• Streamlined complete data submission.

 

Here’s a review of how the online enrollment application works:

The system automatically accesses CAQH to pull in all updated information you’ve already included in your CAQH application.  The CAQH information automatically populates the information Empire needs to complete the enrollment process – including credentialing and loading your new provider to our database.  Please ensure that your provider information on CAQH is updated and is in a complete or re-attested status.

 

Availity’s online application will guide you throughout the enrollment process, providing status updates using a dashboard.  As a result, you know where each provider is in the process without having to call or email for a status. 

 

Please note: For any changes to your practice profile and demographics, continue to use the new online provider maintenance form that allows you to electronically submit to Empire any changes to your practice profile and demographics. Availity administrators and assistant administrators can access the form on Availity>Payer Spaces>Resources.

 

Accessing the provider enrollment application

Log on to the Availity Portal and select Payer Spaces > Empire>Applications>Provider Enrollment to begin the enrollment process. 

 

If your organization is not currently registered for the Availity Portal, the person in your organization designated as the Availity administrator should go to www.availity.com and select Register. 

 

For organizations already using the Availity Portal, your organization's Availity administrator should go to My Account Dashboard from the Availity home page to register new users and update or unlock accounts for existing users. Staff who need access to the provider enrollment tool need to be granted the role of “Provider Enrollment.”

 

(Availity administrators and User Administrators will automatically be granted access to provider enrollment.)

 

If you are using Availity today and need access to provider enrollment, please work with your organization’s administrator to update your Availity role. To determine who your administrator is, you can go to My Account Dashboard > My Administrators.

 

 Need assistance with registering for the Availity Portal? Contact Availity Client Services at 1-800-availity (1-800-282-4548).

 

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As employers across the country host open enrollment periods for their employees, many will offer a new option this fall: plans built around a Blue High Performance Network (Blue HPN). 

 

Blue HPN® plans offer access to providers with a record of delivering high-quality, efficient care. Blue HPN networks will go live January 1, 2021 in more than 50 cities across the country. Blue HPN is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue HPN network. 

 

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

 

Beginning January 1, you may see patients accessing the Blue HPN/Connection Network through new products. These will be EPO plans or HSA plans with an EPO network. Under these plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care. 

 

If you are not sure whether your practice is part of the Blue HPN/Connection Network, ask your office manager or business office, or contact your Empire Provider Relations Representative. Blue HPN participation will be displayed in provider profiles in our online provider directory January 1, 2021.

 

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The New York Department of Financial Services (“DFS”) recently issued a circulator letter, “Charges for Personal Protective Equipment by Participating Providers”. In support with the letter, Empire BlueCross BlueShield (“Empire”) is sharing with participating providers their responsibilities and working with providers to report the findings to DFS.

 

Participating providers are contractually prohibited from charging additional fees for personal protective equipment (PPE) to Empire members as part of their in-person visits. Providers can only charge members for services covered in the policies and/or contracts. Members are not responsible for any charges received from a participating provider beyond their applicable deductible, copayment, or coinsurance, including any fees charged for PPE.

 

If participating providers charged an Empire member for PPE, they should issue a refund to members immediately and contact your Empire Network Services representative to report the following:

• Member(s) impacted
• Total refunded to member(s)
• The refund process

 

You can find the full notification from the New York Department of Financial Services (“DFS”) here: https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2020_14

 

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Empire BlueCross BlueShield (“Empire”) offers you the ability to have a copy of the member’s ID card without having to physically handle the member’s card. This easy, low-touch access to view a member’s ID card is available from the Availity Portal.

 

When conducting an eligibility and benefits inquiry for Empire members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: the Availity Portal requires you to enter the member’s ID number as well as a date of birth or the member’s first and last name into the search options in order to submit an E&B inquiry.

Images of both the front and back of the member ID card are available, allowing you to get all of the pertinent information without the need to make a phone call. The images can be saved directly to your practice management system as PDF files.

 

Another option available is to access the member’s digital version of their ID card as many members have transitioned to using a digital card instead of a paper card. Members are able to  fax or email a copy of the electronic ID card from their phone/app.

 

We encourage you to integrate these options into your workflow now.

 

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If you have questions, you now have a new option to have them answered quickly and easily. With Empire Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.

• Faster access to provider services for all questions
• Real-time answers to your questions about prior authorization, appeals status, claims, benefits, eligibility, and more
• A platform that is easy to use making it simpler to receive help
• The same high level of safety and security you have come to expect with Empire

 

Chat is one example of how Empire BlueCross BlueShield (“Empire”) is using digital technology to improve the health care experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.

 

Use Provider Chat: Select Payer Spaces > Empire > from Applications select Chat.

 

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We are pleased to announce that Interactive Care Reviewer (ICR) is now available to submit outpatient medical authorization requests for Empire BlueCross BlueShield (“Empire”) members enrolled in New York Local, State and City plans.

 

You can now use ICR as your exclusive online self-service digital tool for a majority of your Empire medical and behavioral health authorization requests. This additional capability in ICR will further streamline and boost the efficiency of your organization’s authorization workflow process.

 

If you are new to ICR here are directions to help you get started:

Access to the ICR tool is through the Availity Portal, so you will need to be registered on Availity and have a unique Availity user ID and password. Ask your organization’s Availity administrator to grant you the required ICR role assignment.

• Do you create and submit prior authorization requests?

          Authorization and Referral Request role assignment

• Do you check the status of the case or results of the authorization request?

          Authorization and Referral Inquiry role assignment

 

Once you have the appropriate role assignment you can begin using ICR right away.

• Select Patient Registration from Availity’s home page
• Select Authorizations & Referrals
• Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)

 

Are you new to ICR or need a refresher?

We offer training every month to familiarize new users with ICR features and navigation of the tool. Our next webinar is taking place on October 8 at 11:00 a.m. ET. Register Here

 

Additional ICR resources are available through the Custom Learning Center

Follow the steps outlined below to access self-paced videos located on the Custom Learning Center. From Availity’s home page, select Payer Spaces | Anthem tile | Applications | Custom Learning Center

• Select Catalog from the menu located on the upper left corner of the Custom Learning Center screen
• Use the catalog filter and select Interactive Care Reviewer-Online Authorizations or Authorizations from the Category menu
• Click Apply then enroll for the courses (videos) you want to view.

 

Illustrated reference guides that you can print are located on Custom Learning Center Resources. Select Resources from the menu located on the upper left corner of the screen.  Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print the reference guide.  

 

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Referrals that are required for Empire members enrolled in the Individual Network plan (prefixes VFG or VJD) can now be submitted through Interactive Care Reviewer (ICR), Empire’s online self-service authorization tool. Managing your referral requests using ICR will save you time, and reduce your practice’s paperwork since there is no longer a need to fax.

 

ICR is accessed through the Availity Portal so you will need to be registered on Availity and have a unique Availity user ID and password.

 

To request a referral your Availity administrator needs to grant you the Authorization and Referral Request role assignment.

 

Once you have the appropriate role assignment you can begin using ICR right away.

• Select Patient Registration from Availity’s home page
• Select Authorizations & Referrals
• Select Referrals or select Authorizations

The ICR tool will guide you through the steps to complete your request.

• Patient information; including the member ID, dates of service and number of visits
• Diagnosis and procedure codes
• Requesting and servicing provider information

 

After submitting the referral request you will get this immediate response:  Referral Accepted - No Further Action Required.

 

This information will be saved on your organization’s ICR dashboard, and you will also be able to print the referral details.

 

ICR Training

We offer training every month to familiarize new users with ICR features and navigation of the tool. Our next webinar is taking place on October 8 at 11:00 a.m. ET. Register Here

 

Additional ICR resources are available through the Custom Learning Center

Follow the steps outlined below to access self-paced videos located on the Custom Learning Center. From Availity’s home page, select Payer Spaces | Anthem tile | Applications | Custom Learning Center

• Select Catalog from the menu located on the upper left corner of the Custom Learning Center screen
• Use the catalog filter and select Interactive Care Reviewer-Online Authorizations or Authorizations from the Category menu
• Click Apply then enroll for the courses (videos) you want to view.

 

Illustrated reference guides that you can print are located on Custom Learning Center Resources. Select Resources from the menu located on the upper left corner of the screen.  Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print the reference guide.

 

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Empire BlueCross BlueShield (“Empire”)  providers may now learn how to use Availity's attachment tools to submit and track supporting documentation electronically by attending one of the upcoming live webinars hosted by Availity. 

 

The attachments application is a multi-payer, multi-workflow feature. It allows inclusion of multiple records across a variety of workflows and request types to support different business processes for payers.

 

By attending one of the upcoming webinars, attendees will learn both the digital and electronic processes that include:

• How your organization gets set up
• Demonstrations of the tools used to submit attachments via Availity Portal
• Navigating the Attachments dashboard
• View electronic records of your submissions

 

As part of the session, we will answer questions and provide handouts and a job aid for you to reference later.

 

Register for an upcoming webinar session

1. In Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options.
   • In the Catalog, search by webinar title or keyword (medattach).
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you will receive emails with instructions to join the session.

 

October/November Dates

 

Date	Day	Time
10/07/2020	Wednesday	4:00 p.m. – 5:00 p.m. ET
10/20/2020	Tuesday	11:00 a.m. – 12:00 p.m. ET
11/04/2020	Wednesday	4:00 p.m. – 5:00 p.m. ET
11/17/2020	Tuesday	2:00 p.m. – 3:00 noon ET

 

Where can you find more help?

Select Help & Training > Find Help to display Availity Help in a new browser window.

Use Contents to display topics.

 

Depending on your needs, consider exploring these topics:

• Claim Submission
• Attachments (new)
• Medical Attachments (legacy)

 

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The National Accounts 2021 Pre-certification list is now available for your reference. Please  be sure to continue to verify member eligibility and benefits prior to rendering services.

 

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As providers, you are committed to providing the best care for your patients – our members.  That care may now include telehealth visits.  Recognizing the continuing increased need for telephone and virtual services during the COVID-19 public health emergency, the U.S. Department of Health and Human Services (HHS) has given additional consideration to the treatment of telephone-only services in the HHS-operated Risk Adjustment Program.  HHS has clarified that telephone-only service CPT codes (98966-98968 and 99441-99443) are valid for the Risk Adjustment Program.  Telephone-only visits may benefit your patients who have not participated in, or felt comfortable using, a telehealth video visit.  Thank you for your continued commitment to assessing your patients’ health and closing possible gaps in care.

 

Please contact the Commercial Risk Adjustment Network Education Representative if you have any questions:  Alicia.Estrada@anthem.com.

 

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The What Matters Most online training course for providers and office staff addresses gaps in care and offers approaches to communication with patients.  This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

 

The What Matters Most training can be accessed at: www.patientexptraining.com

 

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Empire BlueCross BlueShield (“Empire”) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

 

Members enrolled in Empire commercial plans will require a medical necessity review of the site of care* for numerous surgical procedures performed in an outpatient hospital setting with dates of service on or after January 1, 2021. Clinical guideline CG-SURG-52, Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services will apply to the review process. AIM Specialty Health_® (AIM) will administer the review.

 

The site of care review will apply to a wide range of surgical procedures, including but not limited to the following specialty categories:

• Auditory system
• Digestive/Gastrointestinal system
• Eye/ocular adnexa system
• Female genital system
• Hemic and lymphatic system
• Integumentary system
• Male genital system
• Musculoskeletal system
• Nervous system
• Respiratory system
• Urinary system

 

For a complete list of procedures included in this site of care review, Frequently Asked Question and additional information, visit aimproviders.com/surgicalprocedures/resources. 

 

AIM will use CG-SURG-52 to evaluate the clinical information in the request and determine if the procedure requested requires a hospital-based outpatient setting. Providers may contact AIM to request a peer-to-peer discussion before or after the review is complete.

 

The site of care review only applies to procedures performed in an outpatient hospital setting. The site of care review does not apply to procedures performed in a non-hospital setting or as part of an inpatient stay, nor when Empire is the secondary payer.

 

Submit a request for review to AIM

Starting December 23, 2020, ordering providers may submit prior authorization requests for the hospital outpatient site of care for the applicable procedures for dates of service on or after January 1, 2021 to AIM in one of the following ways:

• Access AIM’s ProviderPortal_SM at 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 com.
• Call the AIM Contact Center toll-free at 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

Beginning in December, AIM will offer webinars to provide information on navigating the AIM ProviderPortal. To register for a webinar visit aimproviders.com/surgical procedures. 

 

This review applies to local fully insured Empire members and members covered under self-insured (ASO) benefit plans with services medically managed by AIM.  They do not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®).  Providers can view specific guidelines and prior authorization requirements for Empire members on the Prior Authorization page of our empireblue.com/provider. 

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

 

* In some plans, ”level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of or in addition to “site of care” and, in some plans, these terms may be used interchangeably.  For simplicity, Empire will hereafter use “site of care”.

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As recently communicated in the August 2020 edition of Empire BlueCross BlueShield (“Empire”) Provider News, AIM Specialty Health_® (AIM), a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints for Empire Blue Cross members effective November 1, 2020.  Replacement and revision surgeries for procedures such as total joint of ankle, correction of Hallux Valgus, hammertoe repair are included. 

 

The AIM Musculoskeletal Program follows the Empire Clinical Guidelines that state the services must be delivered by a qualified provider within the scope of their licensure. Qualified providers acting within the scope of their license, including podiatrists, who intend to perform certain elective surgeries of the small joints procedures should request prior-authorization for those services through AIM. 

 

AIM will begin accepting prior authorization requests on October 26, 2020 for dates of service on and after November 1, 2020 and after. Prior authorization requests may be submitted via the AIM ProviderPortal or by calling AIM 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

Empire invites you to take advantage of upcoming training sessions that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_SM.  You can register for the 1 hour training sessions:  AIM MSK Small Joint Expansion Training Session 1 on Friday, October 23, 2020, 11am CT or AIM MSK Small Joint Expansion Training Session 2 on Monday, October 26, 2020, 12am CT.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

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As you know, AIM Specialty Health_® (AIM)* administers the Musculoskeletal Program, which includes the medical necessity review of certain surgeries of the spine and joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care.

 

Effective November 1, 2020, according to the AIM Level of Care guideline, it is generally appropriate to perform joint codes (CPT^® codes 27130, 29871, 29892) and four spine codes (CPT codes 22633, 22634, 63265 and 63267) in a hospital outpatient setting. To avoid additional clinical review for these procedures, providers requesting prior authorization should either choose hospital observation admission as the site of service or Hospital Outpatient Department (HOPD). If the provider determines that an inpatient stay is necessary due to postoperative care requirements, they can initiate a concurrent review request for inpatient admission with the health plan by contacting the number on the back of the member ID card.

 

We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

• Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
• Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration or extent of the planned procedure and/or substantial preoperative patient risk.

Peer-to-peer conversations are available to a provider at any time to discuss the applicable clinical criteria and to provide information about the circumstances of a specific member.  

 

Providers should continue to submit pre-service review requests to AIM using one of the following ways:

• Access AIM ProviderPortal_SM directly at http://providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Portal* at https://www.availity.com.
• Call the AIM toll-free number at 1-800-714-0040 Monday through Friday 8:30 a.m. to 7 p.m. ET.

 

If you have questions, please contact provider services at 1-800-450-8753.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield HealthPlus. Availity LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0240-20 August 2020

 

We are pleased to announce that Empire BlueCross BlueShield HealthPlus (Empire) has expanded its collaborative partnership with SOMOS IPA, LLC and its affiliates (SOMOS). This new agreement aligns incentives between the plan and SOMOS to deliver the highest possible quality care to our Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHPlus) and Essential Plan members in New York.

 

Effective October 1, 2020, for MMC, HARP, CHPlus and Essential Plan members in New York assigned to a SOMOS PCP, SOMOS will assume administrative functions including but not limited to: credentialing, population health management/transitional care management, utilization management and claims processing.

 

Prior authorization requests

Providers should contact SOMOS for prior authorizations at 1-844-990-0255.

 

Medical management

To obtain authorization or to verify member eligibility, benefits and account information, please call the telephone numbers listed on the back of the member’s ID card.

 

There are few different ID card layouts. Below is an example of one the ID cards. Other member’s ID cards may vary slightly from example below.

 

Claims processing

SOMOS encourages all claims to be submitted electronically using the below payer ID #s
SOMOS	81508
Paper claims submitted should be submitted to the following:
Attn: SOMOS IPA, LLC PO Box 21432 Eagan, MN 55121
Please note: SOMOS participating network providers must follow the claims protocols established by SOMOS as referenced in the provider’s participating provider agreement with SOMOS IPA. Non-SOMOS participating network providers must continue to submit claims directly to Empire so that we may process the claims in accordance with your Empire contract.

 

Credentialing process

IPA providers: SOMOS will handle all credentialing for its participating providers. This includes submission of any demographic changes or terminations.

 

Non-IPA providers: Providers who are not contracted with the IPA must continue to follow the Empire processes.

 

If you have any questions, please contact Empire’s Provider Services department at 1-844-990-0255.

 

NYE-NU-0205-20 September 2020

 

Effective November 1, 2020, prior authorization (PA) requirements will change for E0482. The medical codes listed below will require PA 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:

• E0482 — Cough stimulating device, alternating positive and negative airway pressure

 

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 by accessing the Provider Self-Service Tool at https://www.availity.com by visiting www.empireblue.com/nymedicaiddoc > Login. Contracted and noncontracted providers who are unable to access Availity* may call Provider Services at 1-800-450-8753 for PA requirements.

 

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

 

NYE-NU-0243-20 August 2020

 

Empire BlueCross BlueShield HealthPlus (Empire) is introducing a program to help ensure members are able to receive necessary asthma controller medications. When a controller inhaler is prescribed and denied at the pharmacy because it is not on our formulary, a pharmacist from Empire will contact the provider’s office to provide formulary alternatives and prior authorization instructions if needed. The goal of this program is to ease the burden on providers in navigating formulary options, as well as to ensure members are able to access necessary medications to control their asthma.

 

NYE-NU-0250-20 August 2020

 

Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Empire patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

 

What’s new: Medical providers now have the option to include feedback for Empire patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

 

Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

 

First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Empire Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

                                                                                                                                      

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.

From the Availity home page, select Payer Spaces > Empire payer tile > Applications > Custom Learning Center

• Select Resources from the menu located on the upper left corner of the page

(To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)

• Select Download to view and/or print the reference guide

 

NYE-NU-0238-20/ EBCCRNU-0127-20  August 2020

512477MUPENMUB

 

Behavioral health disorders are classified in Chapter 5 of the ICD-10-CM

Behavioral health disorders are commonly underreported on claims. Many Empire BlueCross BlueShield HealthPlus members may have behavioral health disorders that are not properly managed. Health care providers can assist by taking detailed histories and coding behavioral health issues properly on claims. Below are the ICD-10-CM coding guidelines for behavioral health conditions.

 

When documenting behavioral disorders, the following descriptors apply:

• Type: Depressive, manic, or bipolar disorder
• Episode: Single or recurrent
• Status: Partial or full remission; identify most recent episode as manic, depressed, or mixed
• Severity: Mild, moderate, severe, or with psychotic elements.

 

Schizophrenic related disorders

Schizophrenic related disorders are classified in category F20, with a forth character indicating the type of schizophrenia as follows:

 

Code	Description
F20.0	Paranoid schizophrenia
F20.1	Disorganized schizophrenia
F20.2	Catatonic schizophrenia
F20.3	Undifferentiated schizophrenia
F20.5	Residual schizophrenia
F20.8	Other schizophrenia This subcategory is further subdivided as follows: F20.81 Schizophreniform disorder F20.89 Other schizophrenia
F20.9	Schizophrenia, unspecified

 

Major depressive disorder (MDD)

Major depressive disorder (MDD) is classified in ICD-10-CM to categories:

• F32.- Major depressive disorder, single episode
• F33.- Major depressive disorder, recurrent.

Categories F32 and F33 are further subdivided with fourth characters, and sometimes fifth characters, to provide information about the current severity of the disorders, as follows:

• 0 Mild
• 1 Moderate
• 2 Severe, without psychotic features
• 3 Severe with psychotic features
• 4 In remission
• 5 In full remission
• 8 Other
• 9 Unspecified.

Fourth characters 1 through 8 are assigned only when provider documentation of severity is included in the medical record.

 

Manic episodes and bipolar disorders

The table below outlines the ICD-10-CM classification for bipolar disorders. Manic/mania also falls within this code category. The codes in these categories require fourth and/or fifth digits to identify the severity of the current episode and whether or not psychotic symptoms are involved.

 

Category	Description
F30.-	Manic episode (includes bipolar disorder, single manic episode, and mixed affective episode)	Select appropriate fourth and fifth digits to identify the severity of the current episode to indicate whether psychotic symptoms are involved
F31.-	Bipolar disorder (includes manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)	Select appropriate fourth and fifth digits to specify the severity of the current episode and whether the current episode is hypomanic, manic, depressed or mixed, and with or without psychotic features.
F34.-	Persistent mood affective disorders (includes cyclothymic disorder and dysthymic disorder)	Includes, cyclothymic, dysthymic, and other specified mood disorders.
F39	Unspecified mood affective disorder (includes affective psychosis not otherwise specified)	Include affective psychosis when not otherwise specified

 

Anxiety disorders

Anxiety disorders are classified in ICD-10-CM under the following categories:

• F40 Phobic anxiety disorders
• F41 Other anxiety disorders
• F42 Obsessive-compulsive disorder.

 

Dissociative and conversion disorders

ICD-10-CM classifies dissociative and conversion disorders to category F44.

 

Dissociative disorders:

 

Code	Description
F44.0	Dissociative amnesia
F44.1	Dissociative fugue
F44.2	Dissociative stupor
F44.81	Dissociative identity disorder

 

Conversion disorders:

 

Code	Description
F44.4	Conversion disorder with motor symptom or deficit
F44.5	Conversion disorder with seizures or convulsions
F44.6	Conversion disorder with sensory symptom or deficit
F44.7	Conversion disorder with mixed symptom presentation

 

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 through F59 grouping includes the following conditions:

 

Category/ code	Description
F50.0-	Eating disorders (such as anorexia nervosa and bulimia nervosa)
F51.-	Sleep disorders not due to a substance or known physiological condition
F52.-	Sexual dysfunction not due to a substance or known physiological condition
F53.-	Mental and behavioral disorders associated with the puerperium, not elsewhere classified
F54	Psychological and behavioral factors associated with disorders or diseases classified elsewhere
F55.-	Abuse of non-psychoactive substances
F59	Unspecified behavioral syndromes associated with physiological disturbances and physical factors

 

Disorders of adult personality and behavior

Categories F60 through F69 include disorders of adult personality and behavior:

 

Category code	Description
F60.0-	Specific personality disorders
F63.-	Impulse disorders
F64.-	Gender identity disorders
F65.-	Paraphilias
F66.-	Other sexual disorders
F68.-	Other disorders of adult personality and behavior

 

Psychosocial circumstances and encounters

ICD-10-CM provides codes for behaviors that have not yet been classified to behavioral disorders, but that may contribute to the need for further treatment or study. The table below shows some examples:

 

Code	Description
R41.0	Disorientation, unspecified
R41.82	Altered mental status, unspecified
R41.840	Attention and concentration deficit
R44.3	Hallucinations, unspecified
R45.83	Excessive crying of child, adolescent or adult
R45.84	Anhedonia
R45.86	Emotional liability
R45.87	Impulsiveness
R46.0	Very low level of personal hygiene
R46.2	Strange and inexplicable behavior
R46.81	Obsessive-compulsive behavior

 

For behavioral health disorders that resolve and do not require continued treatment, it is appropriate to report code Z86.59, Personal history of other mental and behavioral disorders.

 

Resources:

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.
2. ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier.

 

NYE-NU-0237-20 August 2020

 

 

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

• Mail order pharmacy reminder

On December 1, 2020, Empire BlueCross BlueShield prior authorization (PA) requirements will change for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

See attached for a list of prior authorization requirements that will be added.

 

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.empireblue.com/medicareprovider > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.

 

EBSCRNU-0133-20 August 2020

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On January 1, 2021, Empire BlueCross BlueShield prior authorization (PA) requirements changed for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

See attached for a list of prior authorization requirements that will be added.

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.empireblue.com/medicareprovider > Login. Contracted and non-contracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.

 

EBSCRNU-0131-20 August 2020

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Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Empire patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

 

What’s new: Medical providers now have the option to include feedback for Empire patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

 

Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

 

First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Empire Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

                                                                                                                                      

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.

From the Availity home page, select Payer Spaces > Empire payer tile > Applications > Custom Learning Center

1. Select Resources from the menu located on the upper left corner of the page

(To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)

2. Select Download to view and/or print the reference guide

 

NYE-NU-0238-20 August 2020

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Effective October 1, 2020, Empire BlueCross BlueShield (Empire) will integrate community health workers (CHWs) used by GroundGame Health (GGH)* into our current care management program. Referrals into the program are completed via provider direct referrals or ad hoc referrals from the Empire Case Management team. Provider direct referrals will include members with the following situations:

• Identified social determinants of health needs including, but not limited to:
  • Living environment
  • Transportation
  • Food insecurity issues
  • Financial issues
  • Social isolation, etc.
• Hospital readmissions
• A readmission risk score of more than 24

 

GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. PCHP makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from Empire, or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.

 

A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.

 

The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.

 

To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 or email physicianreferral@preferredchp.com.

 

EBSCARE-0416-20 August 2020

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Empire BlueCross BlueShield (Empire) continues to be dedicated to delivering access to quality care for our members, providing higher value to our customers and helping improve the health of our communities. In an ongoing effort to promote accurate claims processing and payment, Empire is taking additional steps to assess selected claims for evaluation and management (E/M) services submitted by professional providers. Beginning on December 1, 2020, we will be using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.

 

Providers should report E/M services in accordance with the American Medical Association (AMA) CPT^® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The appropriate level of service is based primarily on the documented medical history, examination and medical decision-making. Counseling, coordination of care, the nature of the presenting problem and face-to-face time are considered contributing factors. The coded service should reflect and not exceed that needed to manage the member’s condition(s).

 

Claims will be selected from providers who are identified as coding at a higher E/M level as compared to their peers with similar risk-adjusted members. Prior to payment, Empire may review E/M claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is higher than the E/M code level supported on the claim. If the E/M code level submitted is higher than the E/M code level supported on the claim, Empire reserves the right to: 

• Deny the claim and request resubmission of the claim with the appropriate E/M level;
• Pend the claim and request documentation supporting the E/M level billed; and/or
• Adjust reimbursement to reflect the lower E/M level supported by the claim.

 

The maximum level of service for E/M codes will be based on the complexity of the medical decision-making, and reimbursed at the supported E/M code level and fee schedule rate.

 

This initiative will not impact every level four or five E/M claim. Providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.

 

Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute).

 

If you have questions regarding this program, contact your contract manager or Network Relations.

 

EBSCRNU-0127-20 August 2020

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A key goal in our provider transparency initiative is to improve quality while managing health care costs. One of the ways we do that is by offering value-based programs including Freestanding Patient Centered Care (FPCC), Medicare Advantage Enhanced Personal Health Care Essentials and so on (known as the Programs).

 

Value-based program providers (also known as payment innovation providers) in our programs receive quality, utilization and/or cost data, reports, and information about the health care providers (referral providers) to whom the providers may refer their Empire BlueCross BlueShield (Empire) patients. If a referral provider is higher quality and/or lower cost, this component of the Programs should result in the provider receiving more referrals from value-based program providers. The converse should be true if referral providers are lower quality and/or higher cost.

 

Providing this type of data to value-based program providers (including comparative cost information) helps them make more informed decisions about managing health care costs, maintain/improve quality of care and succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representative/vendors) may also be given data about value-based program providers or referral providers to better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Upon request, Empire will share the data used to make these quality/cost/utilization evaluations and will discuss it with referral providers, including any opportunities for improvement.

 

If you have questions or need support, contact your local Market Representative or Care Consultant.

 

EBSCRNU-0132-20 August 2020

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On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting June 2020. Visit Clinical Criteria to search for specific policies.

             

If you have questions or would like additional information, use this email.

 

EBSCRNU-0134-20 August 2020

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

• Medical Policies and Clinical Utilization Management Guidelines update