 Provider News New YorkOctober 2021 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) is committed to helping providers and facilities with hassle-free healthcare administration. To that end, we have simplified the network structure for our Commercial membership. Our three Commercial network offerings are Connection, Blue Access, and PPO/EPO, all housed within a single provider universe. All providers in Connection are in Blue Access, and all providers in Connection and Blue Access are in PPO/EPO - it’s as simplistic as that!
- Connection is a new, custom-tailored narrow network focused on making high-quality care as affordable as possible.
- Member ID prefixes are BCW, BKT, CJL, H9N.
- Blue Access offers in network access to nearly all key hospitals and aligns with our physicians—to make access to high-quality care more affordable.
- Member ID prefixes are BAW, BGW, CFT, XNU, YXE.
- PPO/EPO offers our broadest in-network coverage providing greater access to high-quality care for New Yorkers.
- Member ID prefixes are KIH, NIW, VQA, ZVF, ZYL.
We encourage you to check out our Empire 2021 Provider Guide here which provides the full product names and member prefixes associated with each network.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 
Dr. Langer has over 24 years of experience with various healthcare management organizations. She previously served as Senior Vice President and Chief Medical Officer at Fallon Health, where she led all activities and operations within Fallon Health’s Care Services department. She was responsible for ensuring the quality and cost-effectiveness of healthcare services for Exchange, Commercial, Medicare Advantage, D-SNP/SCO, and Medicaid products. Prior to that, she was the Chief Medical Officer of MassHealth, the Massachusetts state Medicaid program.
Dr. Langer is board-certified in Occupational Medicine. She received her B.A. from the University of Pennsylvania, medical degree from Jefferson Medical College, law degree from Harvard Law School, and a Master of Public Health from the Harvard T.H. Chan School of Public Health. In addition to her academic and professional achievements, Dr. Langer also chairs several non-profit boards and founded a program for post-baccalaureate pre-health professions students to gain experience working with individuals with disabilities.
Along with her impressive experience, Dr. Langer is a Veteran. She is a retired Colonel from the Army National Guard where she served as a Flight Surgeon and Hospital Commander. Empire welcomes Dr. Langer and thanks her on behalf of our community for her military service.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In late 2020, the Price Transparency final rule and the Consolidated Appropriations Act (CAA) were enacted. By law, many of these provisions require that Empire BlueCross BlueShield (“Empire”) must disclose pricing and other information previously not available publicly. Below is a summary of provisions that may impact you. Some sections of these laws are pending further rulemaking/regulations.
Transparency in pricing regulation – Overview of changes and action Empire is taking
Transparency requirements will be phased in over three years beginning July 2022 as follows:
|
Plan years that begin
|
Regulation requirements
|
Empire’s action
|
|
On or after
January 1, 2022
|
Empire must make three separate machine-readable files in a standardized format available to the public, including stakeholders such as consumers, researchers, employers, and third-party developers. The three files must be placed on a publicly available website and updated monthly.
1. Negotiated in-network provider rates for all covered items and services
2. Historical payments to, and billed charges from, out-of-network providers
3. In-network negotiated rates and historical net prices for all covered prescription drugs administered by Empire at the pharmacy location level.
4.
The rate information is required to include the provider’s National Provider Identifier (NPI) and taxpayer identification number (TIN).
|
We are developing the files that will be available through our website for the data we administer and maintain.
Machine Readable Files will be published beginning July 1, 2022, except those for prescription drugs, which are pending further rulemaking.
|
|
January 1, 2023
|
Empire must make personalized out-of-pocket cost information and the underlying negotiated rates for 500 covered healthcare items and services – including prescription drugs – available to participants, beneficiaries, and enrollees.
|
As required, we are on track with making information available through an internet-based, self-service tool and in paper form upon request.
|
|
January 1, 2024
|
Empire must expand our transparency tools to encompass all covered items and services.
|
We continue to review and assess guidance regarding the regulation and are working to comply with requirements.
|
Consolidated Appropriations Act (CAA)
As a part of the Consolidated Appropriations Act or CAA, there are significant new health plan requirements, including protections for patients from surprise medical bills and other significant health coverage related provisions. Most of these provisions are effective January 1, 2022.
Regulatory detail needed for full implementation is still pending in most cases. However, the Centers for Medicare & Medicaid Services (CMS) has indicated good faith compliance should be pursued pending regulatory implementation detail.
Some key provisions of the CAA, effective January 1, 2022, are listed below that may impact your business interactions with us.
Surprise billing and independent dispute resolution process
The CAA requires that patients be held responsible for only in-network cost sharing amounts, including deductibles, in emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider (including air ambulance providers). The provision also prohibits out-of-network providers from balance billing except in limited circumstances where the out-of-network provider has obtained a notice and consent from the patient. An independent dispute resolution (IDR) process is available when an out-of-network provider and Empire cannot reach an agreement on payment.
In July 2021, an interim final rule (IFR) provided some of the regulatory detail around cost sharing calculations for surprise billing. Further regulatory guidance is expected in the coming months – including guidance regarding the IDR process.
Empire is moving forward with changes in calculations and payment based on the guidance received to date. We will continue to monitor for additional regulatory guidance.
Increasing transparency by removing contract provisions known as gag clauses that may prohibit health plans from disclosing price and quality information
The CAA requires Empire to provide access to provider-specific price or quality of care information, through a consumer engagement tool or any other means, to referring providers, enrollees, or individuals eligible to become Empire enrollees.
Due to the gag clause provision, we will no longer be able to allow suppression of price and quality data upon provider request.
Member identification card changes
Member ID cards issued for plan years on and after January 1, 2022, must include information to ensure that members know how to access current information regarding their deductibles and out-of-pocket limits. Additionally, member ID cards must include a telephone number and internet address for members to use for assistance should they have questions such as whether a provider participates in our networks. We encourage in-network providers to continue to use Availity for member cost share information.
Continuity of care
As a part of the Consolidated Appropriations Act, there is a continuity of care protection requirement that allows patients with serious or complex care needs (continuing care patients) to have up to a 90-day period of continued coverage at the same terms and conditions when a provider changes network status or an insured group contract terminates. This provides continued coverage at in-network cost sharing rates to allow for a transition of care to an in-network provider or until the patient is no longer a continuing care patient under the CAA.
Empire must notify individuals who qualify as continuing care patients at the time of the provider’s termination as an in-network provider of the option to continue care for the transitional period of up to 90 days. Providers subject to this provision must accept the continued in-network payment as payment in full and otherwise comply with all policies, procedures and quality standards Empire imposes. If an insured group terminates with Empire, continuing care patients also have up to a 90-day period of continued care at in-network cost sharing rates. Applicable contract rates will apply for providers.
Protecting patients and improving the accuracy of provider directory information
Empire must maintain a provider directory available to consumers online that includes a list of the in-network providers and facilities. Empire must verify provider/facility name, address, specialty, phone number and digital contact information at least every 90 days.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the June 2021 edition of Provider News, we announced additional enhancements to our claims editing systems to include an automated front end adjudication of claims edits.
To clarify, this enhancement does not affect any of our reimbursement policies. The enhanced edits update our claims editing process for outpatient facility claims.
These enhanced edits provide an opportunity to shift certain existing back-end reviews to front-end adjudication for outpatient facility claims including but not limited to scenarios with:
- Revenue code billing
- CPT/HCPCS code reporting
- Modifier usage
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The American Cancer Society estimates there will be approximately 1,898,160 cancer cases diagnosed in 2021. That’s the equivalent of 5,200 new cases each and every day. 1 The good news is, patients say they are more likely to get screened when you recommend it. What else can you do to influence cancer screenings? 2
- Understand the power of the physician recommendation.
- Your recommendation is the most influential factor in whether a person decides to get screened.
- Patients are 90% more likely to get a screening when they reported a physician recommendation.
- “My doctor did not recommend it,” is the primary reason for screening avoidance.
- Recognize cultural barriers that may impact your diverse patients
- Culturally sensitive conversations with your patients can help with fear, embarrassment, anxiety, and misconceptions about screenings.
- Go to mydiversepatients.com for information and resources.
- Measure the screening rates in your practice; it may not be as high as you think.
- Set goals to get screening rates up.
- Follow the HEDIS guidelines included in this article to help accurately track your care gap closures.
- More screening doesn’t have to mean more work for you.
- Reach out to us about available member data – we may be able to help identify or supply access to data for those members who are due screenings.
- Develop a reminder system, which has been demonstrated to be effective, to remind you and staff that patients have screenings due.
- Help members access benefit information about screenings to eliminate the cost barrier.
- Log onto Availity.com and use the Patient Information tab to run an Eligibility and Benefits inquiry.
- Members can access their benefit information by logging onto empireblue.com, through Live Chat, or by downloading the Sydney Health App.
- Blue Cross Blue Shield Service Benefit Plan members, also known as Federal Employee Program® members, can access their benefit information by logging onto org, or by downloading the fepblue App from the Apple Store or on Google Play.
Measure up: HEDIS® measure specifications for cancer screenings for women
Cervical cancer screening
Organized and continuous screenings along with removal of precancerous lesions can lead to a 60% decrease in cervical cancer.3
Cervical cancer screening is measured by the percentage of women, 21 to 64 years of age who were screened for cervical cancer using either of the following criteria:
- Women 21 to 64 years of age who had cervical cytology performed within the last 3 years.
- Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
- Women 30 to 64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years.
|
Description
|
CPT/HCPCS Code
|
|
Cervical cytology lab test
|
CPT: 88141–88143, 88147, 88148, 88150, 88152–88153, 88164–88167, 88174, 88175
HCPCS: G0123, G0124, G0141, G0143, G0145, G0147, G0148, P3000, P3001, Q0091
LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
|
|
hrHPV lab test
|
CPT: 87620–87622, 87624, 87625
HCPCS: G0476
LOINC: 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0
|
|
Absence of cervix diagnosis
|
ICD-10-CM: Q51.5, Z90.710, Z90.712
|
|
Hysterectomy with no residual cervix
|
CPT: 51925, 56308, 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290–58294, 58548, 58550, 58552, 58553, 58554, 58570–58573, 58575, 58951, 58953, 58954, 58956, 59135
ICD-10-PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ
|
Breast cancer screening
More women in the United States are surviving and thriving after breast cancer than ever before. In fact, in the last 30 years, the breast cancer death rate has dropped an astounding 40%. The decreases are believed to be the result of finding breast cancer earlier through screening, increased awareness, and better treatments.4
Breast cancer screening is measured by the percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer. Compliant members have one or more mammograms any time on or between October 1st two years prior to the measurement year and December 31st of the measurement year.
|
Description
|
CPT/HCPCS Code
|
|
Mammography
|
CPT: 77057, 77061–76063, 77065–77067
LOINC: 24604-1, 24605-8, 24606-6, 24610-8, 26175-0, 26176-8, 26177-6, 26287-3, 26289-9, 26291-5, 26346-7, 26347-5, 26348-3, 26349-1, 26350-9, 26351-7, 36319-2, 36625-2, 36626-0, 36627-8, 36642-7, 36962-9, 37005-6, 37006-4, 37016-3, 37017-1, 37028-8, 37029-6, 37030-4, 37037-9, 37038-7, 37052-8, 37053-6, 37539-4, 37542-8, 37543-6, 37551-9, 37552-7, 37553-5,
37554-3, 37768-9, 37769-7, 37770-5, 37771-3, 37772-1, 37773-9, 37774-7, 37775-4, 38070-9, 38071-7, 38072-5, 38090-7, 38091-5, 38807-4, 38820-7, 38854-6, 38855-3, 42415-0, 42416-8, 46335-6, 46336-4, 46337-2, 46338-0, 46339-8, 46350-5, 46351-3, 46356-2, 46380-2, 48475-8, 48492-3, 69150-1, 69251-7, 69259-0
|
|
Online assessments
|
CPT: 98970–98972, 99421–99423, 99457
HCPCS: G0071, G2010, G2012, G2061–G2063
|
|
Telephone visits
|
CPT: 98966–98968, 99441–99443
|
Chlamydia screening in women
Sexual health is an essential element of overall health and well-being. Many patients want to discuss their sexual health with you, but most of them want you to bring it up. The National Coalition for Sexual Health has published a guide to help physicians feel comfortable about the conversation. Get a copy of the Sexual Health and Your Patients: A Providers Guide by clicking on the title or through this website: ctcfp.org.
Chlamydia screening in women is measured by the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
|
Description
|
CPT/HCPCS Code
|
|
Chlamydia tests
|
CPT: 87110, 87270, 87320, 87490–87492, 87810
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. African American and Hispanic women have higher risk of death from breast cancer than their White counterparts.1
Race and ethnicity continue to be a factor influencing mammography use according to a National Library of Medicine.2 While research and studies show that annual screenings greatly reduce breast cancer deaths, 35% of women still do not get an annual mammogram and the percentage is even higher in African American and Hispanic women.
While African American and White women get breast cancer at about the same rate, African American women have a higher rate of death from breast cancer, according to the Centers for Disease Control and Prevention. African American and Hispanic women are 20% more likely to be diagnosed with advanced stage breast cancer, and they have, respectively, up to 70% and 14% increased risk of death.4
A common theme stressed in all of the major breast screening guidelines has been for providers to talk with patients about mammography. But when? Knowing that younger African American and Hispanic women are already considered a “high-risk” group, the conversation can be confusing to your patient under 30.
Help your African American and Hispanic patients understand the importance of early screening by sharing information with them about their unique risks. We’ve included links to videos that address breast cancer screening in both African American and Hispanic women. We hope you will share it with your patients either in your waiting rooms, or by offering to play them during their visits.
Why mammograms matter for Black women.
Why mammograms matter for Hispanic women.
There are other resources available through the Center for Disease control and the American Cancer Society, to name a few. The American College of Radiology has a Talking to Patients about Breast Cancer Screening CME Toolkit that offers CME credits for completing the toolkit.
Talking to women about taking everyday steps to lower their risk for getting breast cancer is the first step in closing disparity gaps in care.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
If you missed our live continuing medical education (CME) webinars, you can still register for the recorded webinars and earn CME credits. Join our CME webinar series and learn best practices to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs performance.
Program objectives:
- Learn strategies to help you and your care team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.
Attendees will receive one CME credit upon answering required questions at the conclusion of each webinar.
REGISTER HERE for our upcoming live and on-demand clinical quality webinars.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The clinical appeal process is designed to provide appropriate and timely review when providers disagree with a decision made by Empire BlueCross BlueShield (“Empire”). The procedures also meet requirements of state laws and accreditation agencies. Appeals can be made verbally, in writing, or by using Interactive Care Reviewer through the Availity portal.
Clinical appeals refer to a situation in which an authorization or claim for a service was denied as not medically necessary or experimental/investigational. Medical necessity and prior authorization appeals are different than claim payment disputes and should be submitted in accordance with the clinical appeal process.
To learn more about our appeals process in detail, we encourage you to go to Empire’s provider manual, available on our website at https://www.empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Some time ago, Empire BlueCross BlueShield (“Empire”) introduced the ability to submit claim payment disputes via Availity, for members enrolled in our Empire Medicaid and Medicare Advantage benefit plans, as part of our more streamlined provider claims payment dispute process. Effective October 5th, 2021, providers will now also be able to submit claim payment disputes via Availity for Empire’s Commercial lines of business. This does not include members covered under the Federal Employee Program.
As a reminder, unlike inquiries about claims status, provider appeals, or requests for additional information, provider claim payment disputes occur after a claim is finalized, and a provider disagrees with the claim payments Empire has issued. Some examples include claim disputes regarding manual processing errors, contract interpretation, reduced payments, code editing issues, Other Health Insurance denials, eligibility issues, timely filing issues *, and so forth.
The Availity tool allows a more cohesive and efficient approach for providers when:
- Filing a claim payment dispute.
- Sending supporting documentation to Empire.
- Checking the status of a claim payment dispute.
- Viewing the history of a claim payment dispute.
* Reminder- we will consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can: 1) provide documentation that the claim was submitted within the timely filing requirements or 2) demonstrate good cause exists.
Reminder on how the provider claim payment dispute process works
For Empire, the provider claim payment dispute process consists of two steps:
- Claim payment reconsideration: As the first step, the reconsideration represents providers’ initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step. Providers may submit the claim dispute via customer service (refer to the phone number on the back of the member’s ID card), in writing, or effective October 5th, 2021 - via Availity. Providers are encouraged to submit all reconsiderations via Availity. Providers are only allowed one claim payment reconsideration per claim.
Empire will make every effort to resolve the claims payment reconsideration within 30 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days. We will mail you a written extension letter before the expiration of the initial 30 calendar days.
- Claim payment appeal: In this second step, providers who disagree with the outcome of the reconsideration may request an additional review as a claim payment appeal. However, we cannot process an appeal without a reconsideration on file. Providers may submit the claim dispute in writing or effective October 5th, 2021 via Availity; providers are encouraged to submit all appeals via Availity.
When submitting a claim payment appeal, please include as much information as you can to help us understand why you think the reconsideration determination was in error. If a claim payment appeal requires clinical expertise, it will be reviewed by appropriate Empire clinical professionals.
Empire will make every effort to resolve the claim payment appeal within 60 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 60 additional calendar days. We will mail you a written extension letter before the expiration of the initial 60 calendar days.
Submitting claim payment disputes in writing
When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request Form and submit to:
Empire BlueCross BlueShield
Provider Payment Disputes
P.O. Box 1407, Church Street Station
New York, NY 10008
Submitting claim payment disputes via Availity- preferred method, as of October 5th, 2021
For step-by-step instructions to submit a claim payment dispute through Availity:
- Log into Availity at availity.com .
- Select Help & Training | Find Help.
- Under Contents, select Overpayments and Appeals.
- Select Dispute a Claim.
Through Availity, you can upload supporting documentation and receive immediate acknowledgement of your submission.
Empire’s review and providers’ other options
Empire will review the claim payment dispute once received and communicate an outcome in writing or through the Availity Portal. Providers can check the status of a claim payment dispute on the Availity portal at any time.
If a provider still disagrees with the reconsideration, the provider can then choose to submit the claim payment appeal. Once the claim payment appeal is submitted, the decision is final. A claim payment dispute may not be submitted again. Providers can contact their state regulatory agency for additional assistance.
Empire requires providers to use our claims payment reconsideration process if providers feel a claim was not processed correctly.
Once providers complete both the Reconsideration and Appeal processes, providers can contact their Provider Experience Consultant for further assistance. However, providers are required to complete both the Reconsideration and Appeal processes before contacting their Provider Experience Representative for further assistance.
Webinars available
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained.
- Select Sessions and go to Your Calendar to locate a webinar.
- Select View Course and then select Enroll.
- The Availity Learning Center will email you with instructions to attend.
As always, providers can refer to the Provider Manual, as the manual includes additional information about inquiries, the provider claim dispute process, reconsiderations and appeals.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the coming months, we will be enhancing your ability to search, review and download a copy of the remittance advice on Availity when there is no associated payment. For remittance advices with payments, you may continue to search with the check/EFT number.
What’s changing?
- Non-payment number display in the Check Number and Check/EFT Number fields:
- Current - Today, there are two sets of numbers for the same remittance advice. The paper remittance displays 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displays 27 bytes (9999999999 – [year] #############).
- Enhancement - The updated numbering sequence for the paper remittance and corresponding 835 (ERA) will contain the same ten-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.
- Searching for non-payment remittance:
- Current - When using Remit Inquiry, the search field requires a date range and tax ID to locate a specific remittance due to same number scenario being used for every non-payment remittance.
- Enhancement - Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers will provide a faster and simplified process to find the specific remittance.
The way your organization receives remittances and payments is not changing; we have simply enhanced the numbering for the non-pay remittances. These changes will not impact previously issued non-payment remittance advices. We’ll provide further information before this change is implemented.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a reminder, effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub as the electronic funds transfer (EFT) enrollment portal for Empire BlueCross BlueShield (“Empire”) providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users. CAQH Enrollhub is the only CAQH tool being decommissioned. All other CAQH tools will not be impacted.
Benefits of EFT
Not only is receiving your payment more convenient, so is signing up for EFT. When you sign up for EFT through EnrollSafe, the new enrollment portal, you’ll receive your payments up to seven days sooner than through the paper check method. What’s more, it’s easier to reconcile your direct deposits.
Secure and available 24-hours a day – EnrollSafe
Beginning November 1, 2021, if you need to make changes to an existing EFT enrollment or create a new first-time account, log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org to enroll in EFT. Once you have completed registration, you’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
Please note if you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use EnrollSafe to update your account.
Electronic remittance advice (ERA) makes reconciling your EFT payments easy and paper-free
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposits – securely and safely. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on Availity.
ERAs can be retrieved directly from Availity. Log onto Availity and select Claims and Payments > Send and Receive EDI Files > Received Files folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice under Payer Spaces > Remittance Inquiry tool.
Contact information
|
Electronic Remittance Advice (ERA), Electronic Funds Transfer (EFT) registration
and contact information
|
|
Type of transaction:
|
How to register, update, or cancel:
|
For registration related questions, contact:
|
To resolve issues after registration, contact:
|
|
EFT only
|
Use EnrollSafe
|
EnrollSafe help desk at
1-877-882-0384
|
EnrollSafe help desk at
1-877-882-0384
|
|
ERA (835) only
|
Use Availity
|
Availity Support
1-800-282-4548
|
Availity at 1-800-282-4548
NOTE – Providers should allow up to 10 business days for ERA enrollment processing.
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Find Care, the doctor finder and transparency tool in Empire BlueCross BlueShield’s (Empire”) online directory, allows Empire members to search and compare cost and quality measures for in-network providers. This tool allows members to sort providers based on distance, name, or personalized match. Additionally, as communicated earlier this year, the enhanced personalized match sorting option is now available to search by procedure type in addition to providers.
The algorithms used to sort procedure type use a combination of member and provider features to sort and display the results for a member’s search. The sorting results take into account member factors such as the member’s medical conditions and demographics. Provider factors such as surgeon-facility pairing (an individual provider who performs a procedure at a specific facility), cost efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.
Combined member and provider features generate a unique ranking of surgeon-facility pairings or facility providers for each member conducting the procedure search. Displayed first are surgeon-facility pairings with the highest overall ranking within the search radius. Remaining pairings are displayed in descending order based on overall rank and proximity to the center of the search radius.
Personalized match procedure searches is expanding to include additional procedures on or after November 19, 2021. Empire will use an updated episode of care methodology for these new procedures. The episode of care methodology for procedure searches that became available earlier this year will remain unchanged. The personalized match methodology for specialty-based provider searches remains unchanged. Members continue to have the ability to sort from a variety of orders such as distance. This enhancement in sorting methodology has no impact on member benefits.
You may review a copy of the procedure sorting methodologies, including the updated episode of care methodology for procedures added on or after November 19, 2021, by going to Availity and then using the following navigation: Payer Spaces > Empire BlueCross BlueShield > Information Center > Administrative Support > Personalized Provider Procedure Search Methodology.
If you have general questions about the Find Care tool or the change to the quality measures for procedure searches, please contact local Empire consultant.
If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors, you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material adverse change (MAC) notification
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 empireblue.com.
*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.
To view medical policies and utilization management 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 08-19-2021
(The following policy was revised to expand medical necessity indications or criteria.)
- 00121 - Transcatheter Heart Valve Procedures
Revised Medical Policies Effective 09-18-2021
(The following policies were revised to expand medical necessity indications or criteria.)
- 00032 - Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
- 00077 - Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
- 00119 - Endobronchial Valve Devices
Revised Medical Policies Effective 10-01-2021
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- 00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- 00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- 00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- 00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
- 00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
- 00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- 00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- 00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
- 00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
- 00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
- 00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
- 00035 - Other Stem Cell Therapy
Revised Medical Policies Effective 10-06-2021
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- 00006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
- 00025 - Self-Operated Spinal Unloading Devices
- 00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
- 00020 - Gene Expression Profile Tests for Multiple Myeloma
- 00023 - Gene Expression Profiling of Melanomas
- 00033 - Genetic Testing for Inherited Peripheral Neuropathies
- 00034 - SensiGene® Fetal RhD Genotyping Test
- 00047 - Methylenetetrahydrofolate Reductase Mutation Testing
- 00011 - Analysis of Proteomic Patterns
- 00019 - Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
- 00028 - Serum Biomarker Tests for Multiple Sclerosis
- 00029 - Rupture of Membranes Testing in Pregnancy
- 00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
- 00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- 00055 - Wearable Cardioverter Defibrillators
- 00082 - Quantitative Sensory Testing
- 00089 - Quantitative Muscle Testing Devices
- 00095 - Anterior Segment Optical Coherence Tomography
- 00096 - Low-Frequency Ultrasound Therapy for Wound Management
- 00099 - Electromagnetic Navigational Bronchoscopy
- 00103 - Automated Evacuation of Meibomian Gland
- 00134 - Noninvasive Heart Failure and Arrhythmia Monitoring System
- 00057 - Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
- 00061 - PET/MRI
- 00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
- 00008 Mechanized Spinal Distraction Therapy
- 00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- 00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
- 00088 - Coblation® Therapies for Musculoskeletal Conditions
- 00092 - Implanted Devices for Spinal Stenosis
- 00101 - Suprachoroidal Injection of a Pharmacologic Agent
- 00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
- 00107 - Prostate Saturation Biopsy
- 00114 - Facet Joint Allograft Implants for Facet Disease
- 00128 - Implantable Left Atrial Hemodynamic Monitor
- 00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
- 00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
- 00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- 00153 - Cardiac Contractility Modulation Therapy
- 00156 - Implanted Artificial Iris Devices
- 00157 - Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
- 00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
Archived Medical Policy Effective 10-06-2021
(The following policy has been archived.)
- MED.00085 - Antineoplaston Therapy
Archived Medical Policies Effective 10-09-2021
(The following policies have been archived.)
- 00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
- 00037 - Whole Body Computed Tomography Scanning
Revised Medical Policies Effective 10-16-2021
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- 00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
- 00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
New Medical Policies Effective 01-01-2022
(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.)
- 00043 - Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
- 00058 - TruGraf Blood Gene Expression Test for Transplant Monitoring
- 00040 - Serum Biomarker Tests for Risk of Preeclampsia
- 00042 - Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy for Rheumatoid Arthritis
Revised Medical Policy Effective 01-01-2022
(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.)
- 00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
New Medical Policy Effective 01-15-2022
(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- OR-PR.00007 - Microprocessor Controlled Knee-Ankle-Foot Orthosis
Clinical Guideline Updates
Revised Clinical Guidelines Effective 08-19-2021
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
- CG-MED-55 - Site of Care: Advanced Radiologic Imaging
- CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
Revised Clinical Guidelines Effective 10-06-2021
(The following adopted guidelines were reviewed and 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-MED-63 - Treatment of Hyperhidrosis
- CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
- CG-MED-65 - Manipulation Under Anesthesia
- 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-28 - Transcatheter Uterine Artery Embolization
- 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-55 - Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
- CG-SURG-79 - Implantable Infusion Pumps
- CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Revised Clinical Guideline Effective 10-16-2021
(The following adopted guideline was reviewed and had no significant changes to the policy position or criteria.)
- CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
Revised Clinical Guidelines Effective 10-16-2021
(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- CG-MED-68 - Therapeutic Apheresis
- CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
Revised Clinical Guideline Effective 01-01-2022
(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-44 - Electric Tumor Treatment Field (TTF)
Revised Clinical Guideline Effective 01-15-2022
(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-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material adverse change (MAC) notification
Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.
The following Clinical Criteria documents were endorsed at the August 20, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised Clinical Criteria effective September 1, 2021
The following clinical criteria was reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0007 Synagis (palivizumab)
Revised Clinical Criteria effective September 1, 2021
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0020 Tysabri (natalizumab)
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0124 Keytruda (pembrolizumab)
Revised Clinical Criteria effective September 20, 2021
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0001 Erythropoiesis Stimulating Agents
- ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0104 Levoleucovorin Agents
- ING-CC-0169 Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
- ING-CC-0193 Evkeeza (evinacumab)
Revised Clinical Criteria effective September 20, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0004 H.P. Acthar Gel (repository corticotropin injection)
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
- ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0036 Naltrexone Implantable Pellets
- ING-CC-0044 Exondys 51 (eteplirsen)
- ING-CC-0058 Octreotide Agents
- ING-CC-0082 Onpattro (patisiran)
- ING-CC-0100 Istodax (romidepsin)
- ING-CC-0139 Evenity (romosozumab-aqqg)
- ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)
- ING-CC-0152 Vyondys 53 (golodirsen)
- ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy
- ING-CC-0172 Viltepso (viltolarsen)
- ING-CC-0174 Kesimpta (ofatumumab)
- ING-CC-0176 Beleodaq (belinostat)
- ING-CC-0179 Blenrep (belantamab mafodotin-blmf)
- ING-CC-0180 Monjuvi (tafasitamab-cxix)
- ING-CC-0181 Veklury (remdesivir)
- ING-CC-0189 Amondys 45 (casimersen)
- ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
Revised Clinical Criteria effective October 1, 2021
The following clinical criteria were updated with new procedure and/or diagnosis codes)
- ING-CC-0100 Istodax (romidepsin)
- ING-CC-0150 Kymriah (tisagenlecleucel)
- ING-CC-0151 Yescarta (axicabtagene ciloleucel)
- ING-CC-0168 Tecartus (brexucabtagene autoleucel)
- ING-CC-0171 Zepzelca (lurbinectedin)
- ING-CC-0173 Enspryng (satralizumab-mwge)
- ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
- ING-CC-0189 Amondys 45 (casimersen)
- ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
- ING-CC-0192 Cosela (trilaciclib)
- ING-CC-0193 Evkeeza (evinacumab)
- ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
- ING-CC-0195 Abecma (idecabtagene vicleucel)
- ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
- ING-CC-0197 Jemperli (dostarlimab)
- ING-CC-0201 Rybrevant (amivantamab-ymjw)
Revised Clinical Criteria effective January 1, 2022
The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0001 Erythropoiesis Stimulating Agents
- ING-CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
- ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- ING-CC-0027 Denosumab Agents
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0034 Hereditary Angioedema Agents
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0081 Crysvita (burosumab-twza)
- ING-CC-0096 Asparagine Specific Enzymes
- ING-CC-0104 Levoleucovorin Agents
- ING-CC-0156 Reblozyl (luspatercept)
- ING-CC-0182 Agents for Iron Deficiency Anemia
New Clinical Criteria effective January 1, 2022
The following clinical criteria are new.
- ING-CC-0202 Saphnelo (anifrolumab-fnia)
- ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material adverse change (MAC) notification
As we previously communicated, Empire BlueCross BlueShield’s (“Empire”) Designated Specialty Pharmacy Network requires providers who are not part of the Designated Specialty Pharmacy Network to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through CVS Specialty Pharmacy.
This update is to advise of the following changes:
Effective for dates of service on and after January 1, 2022, the following specialty pharmacy medications will be added to the Designated Medical Specialty Pharmacy drug list. Accordingly, hospitals that are not in the Designated Specialty Pharmacy Network will be required to acquire these specialty medications administered in the hospital outpatient setting from CVS Specialty Pharmacy.
|
HCPCS
|
Description
|
Brand Name
|
|
J1554
|
Injection, immune globulin (asceniv), 500 mg
|
Asceniv
|
|
J7204
|
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu
|
Esperoct
|
|
J7208
|
Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.
|
Jivi
|
|
J7212
|
Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram
|
Sevenfact
|
|
J9144
|
Injection, daratumumab, 10 mg and hyaluronidase-fihj
|
Darzalex Faspro
|
To access the current Designated Medical Specialty Pharmacy drug list, please visit empireblue.com/provider, > select Find Forms > scroll down and select Pharmacy in the Category drop down. The Designated Medical Specialty Pharmacy drug list may be updated periodically by Empire.
If you have questions or would like to discuss the terms and conditions to be included as a Designated Specialty Pharmacy Network provider, please contact your Empire Contract Manager. Thank you for your continued participation in the Empire networks and the services you provide to our members.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material adverse change (MAC) notification
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.
Please note that 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.
Site of care updates
Effective for dates of service on and after January 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0062
|
Q5121
|
Avsola
|
|
*ING-CC-0081
|
J0584
|
Crysvita
|
|
*ING-CC-0162
|
J3241
|
Tepezza
|
* Non-oncology use is managed by the medical specialty drug review team.
Quantity limit updates
Effective for dates of service on and after January 1, 2022, 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-0009
|
Lemtrada
|
J0202
|
|
ING-CC-0011
|
Ocrevus
|
J2350
|
|
ING-CC-0014
|
Avonex
|
J1826
|
|
Q3027
|
|
Betaseron
|
J1830
|
|
Copaxone
|
J1595
|
|
Extavia
|
J1830
|
|
Glatopa
|
J1595
|
|
Plegridy
|
J3590
|
|
C9399
|
|
Rebif
|
J1826
|
|
Q3028
|
|
ING-CC-0020
|
Tysabri
|
J2323
|
|
ING-CC-0029
|
Dupixent
|
J3490
|
|
J3590
|
|
ING-CC-0038
|
Bonsity
|
J3110
|
|
Forteo
|
J3110
|
|
Tymlos
|
C9399
|
|
J3490
|
|
ING-CC-0042
|
Siliq
|
C9399
|
|
J3490
|
|
J3590
|
|
Taltz
|
C9399
|
|
J3490
|
|
J3590
|
|
ING-CC-0048
|
Spinraza
|
J2326
|
|
ING-CC-0062
|
Avsola
|
Q5121
|
|
Erelzi
|
J3590
|
|
Eticovo
|
J3590
|
|
ING-CC-0066
|
Kevzara
|
C9399
|
|
J3590
|
|
J3490
|
|
ING-CC-0075
|
Riabni
|
Q5123
|
|
ING-CC-0077
|
Palynziq
|
C9399
|
|
J3590
|
|
ING-CC-0082
|
Onpattro
|
J0222
|
|
ING-CC-0156
|
Reblozyl
|
J0896
|
|
ING-CC-0159
|
Scenesse
|
J7352
|
|
ING-CC-0160
|
Vyepti
|
J3032
|
|
ING-CC-0162
|
Tepezza
|
J3241
|
|
ING-CC-0163
|
Durysta
|
J7351
|
|
ING-CC-0170
|
Uplizna
|
J1823
|
|
ING-CC-0172
|
Viltepso
|
J1427
|
|
ING-CC-0173
|
Enspryng
|
J3490
|
|
J3590
|
|
ING-CC-0174
|
Kesimpta
|
C9399
|
|
J3490
|
|
J3590
|
|
ING-CC-0177
|
Zilretta
|
J3304
|
|
ING-CC-0181
|
Veklury
|
J3490
|
|
ING-CC-0183
|
Sogroya
|
J3590
|
|
ING-CC-0185
|
Oxlumo
|
J0224
|
|
ING-CC-0188
|
Imcivree
|
J3490
|
|
J3590
|
|
ING-CC-0193
|
Evkeeza
|
J3490
|
|
C9079
|
|
ING-CC-0194
|
Cabenuva
|
J3490
|
|
C9077
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Visit Pharmacy Information for providers on empireblue.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes
- Drug lists and changes
- Prior authorization criteria
- Procedures for generic substitution
- Therapeutic interchange
- Step therapy or other management methods subject to prescribing decisions
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
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 for Empire.
Effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub ® as the electronic funds transfer (EFT) enrollment website for Empire providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users.
When you sign up for EFT through https://enrollsafe.payeehub.org, the new enrollment website, you’ll receive your payments up to seven days sooner than through the paper check method. Not only is receiving your payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.
EnrollSafe is safe, secure and available 24-hours a day
Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org to enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use https://enrollsafe.payeehub.org to update your account.
Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposit. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on the Availity* Portal. To access the ERA, log onto https://www.availity.com and use the Claims and Payments tab. Select Send and Receive EDI Files, then select Received Files Folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice through the Remittance Inquiry app.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Comprehensive Diabetes Care HEDIS® measure
The Comprehensive Diabetes Care HEDIS measure evaluates the percent of adult members 18 to 75 years of age with diabetes (type 1 and type 2) who had each of the following during the measurement year:
- Hemoglobin A1c (HbA1c) testing
- HbA1c poor control (>9.0%)
- HbA1c control (<8.0%)
- Retinal eye exam performed
- Blood pressure control (<140/90 mm Hg)
Kidney Health Evaluation for Patients with Diabetes
Additionally, the Kidney Health Evaluation for Patients with Diabetes measure was added as a first year HEDIS measure in 2020. This measure evaluates the percent of members 18 to 85 years of age with diabetes who received a kidney health evaluation, including an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR).
Record your efforts
Document results in the in the member’s medical record: HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test, GFR test.
Helpful tips:
- Have reminders set in your electronic medical record (EMR) to alert staff when a patient’s screenings are due.
- Provide reminders to patients for upcoming appointments and screenings.
- Draw labs in your office if available or refer patients to a local lab for screenings.
- Refer patients to participating eye professionals for annual retinal eye exams.
- Follow up on lab test, eye exams and specialist referrals and document in your chart.
- Telephone visits, e-visits and virtual check-ins are acceptable settings for blood pressure readings and should be recorded in the chart.
- Include Category II reporting codes on claims to reduce the burden of HEDIS medical record review.
- Educate patients on topics (for example, home monitoring of blood sugar and blood pressure, taking medications as prescribed, and other healthy lifestyle education like diet, exercise, and smoking cessation).
Other available resources:
- Clinical Practice Guidelines are available on our provider self-service website.
- Contact the Health Plan for a copy of Quality Measures Desktop Reference for Medicaid Providers and the HEDIS Benchmarks and Coding Guidelines for Quality.
- Diabetes programs may be available to our members, contact your Provider Solutions representative for more information.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (Effective 01/01/22)
Empire BlueCross BlueShield HealthPlus (Empire) allows reimbursement of sexually transmitted infection (STI) tests unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. We consider certain STI testing CPT® codes to be part of a laboratory panel grouping. When Empire receives a claim with two or more single tests laboratory procedure codes reported, we will bundle those two or more single tests into the comprehensive laboratory procedure code listed below.
Applicable single STI CPT codes:
- 87491: Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, amplified probe technique
- 87591: Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, amplified probe technique
- 87661: Infectious agent detection by nucleic acid (DNA or RNA); trichomonas vaginalis, amplified probe technique
Applicable comprehensive code:
- 87801: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique
Empire will reimburse the more comprehensive, multiple organism code for infectious agent detection by nucleic acid, amplified probe technique (CPT code 87801), when two or more single test CPT codes are billed separately by the same provider on the same date of service. Reimbursement will be made based on a single unit of CPT code 87801 regardless of the units billed for a single code. No modifiers will override the edit.
For additional information, please review the Sexually Transmitted Infections Testing — Professional reimbursement policy at https://providerpublic.empireblue.com.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Q.What will be the new AIM Specialty Health® (AIM)* phone number for Empire BlueCross BlueShield HealthPlus (Empire)?A. The new phone number will be 855-574-6481.
Q. When is the anticipated go-live date for providers to begin using the new phone number?A. The anticipated effective date is September 1, 2021.
Q. What will happen to the previous AIM number?
A. The number will remain active; however, Empire providers will need to dial the new phone number for further assistance.
AIM will continue to transition other Medicaid markets to their own unique phone line. The existing number must remain active until all markets are no longer using the previous number. The target completion date for this transition will be by quarter 4 in 2022, and the previously used phone number will be discontinued by quarter 1 in 2023.
Q. Will the new number be applicable to Medicare as well?
A. No, this new number is only for Medicaid. Medicare will have a separate phone number.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative 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. Effective for dates of service on and after November 1, 2021, the following specialty drug codes from current or new clinical criteria documents will require prior authorization.
Please note, inclusion of national drug code (NDC) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Visit the Clinical Criteria website to search for the specific clinical criteria listed below.
|
Clinical Criteria
|
HCPCS or CPT® code(s)
|
Drug
|
Drug classification
|
|
ING-CC-0170
|
J1823
|
Uplizna
|
Immunosuppressive agents
|
|
ING-CC-0172
|
J3490, J3590, C9071
|
Viltepso
|
Muscular dystrophies
|
|
ING-CC-0173
|
J3490, J3590
|
Enspryng
|
MISC conditions
|
|
ING-CC-0174
|
J3490, J3590, C9399
|
Kesimpta
|
Multiple sclerosis
|
|
ING-CC-0168
|
J9999, C9073
|
Tecartus
|
CAR-T
|
|
ING-CC-0171
|
J9223
|
Zepzelca
|
Cancer
|
|
ING-CC-0169
|
J9316
|
Phesgo
|
Cancer
|
|
ING-CC-0175
|
J9015
|
Proleukin
|
Cancer
|
|
ING-CC-0176
|
J9032
|
Beleodaq
|
Cancer
|
|
ING-CC-0178
|
J9262
|
Synribo
|
Cancer
|
|
ING-CC-0177
|
J3304
|
Zilretta
|
Osteoarthritis
|
|
ING-CC-0002
|
Q5122
|
Nyvepria
|
Blood cell deficiency
|
|
ING-CC-0038
|
J3110
|
Forteo
|
Osteoporosis
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new Clinical Criteria documents will require prior authorization.
Please note, inclusion of a national drug code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.
|
Clinical Criteria
|
HCPCS or CPT® code(s)
|
Drug
|
Generic name
|
Drug class
|
|
ING-CC-0179
|
J9037
|
Blenrep
|
Belantamab
|
Oncology
|
|
ING-CC-0180
|
J9349
|
Monjuvi
|
Tafasitamab-cxix
|
Oncology
|
|
ING-CC-0181
|
J3490
|
Veklury
|
Remdesivir
|
COVID-19
|
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative 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. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We are offering webinars to help you understand the upcoming changes for City of New York retirees transitioning to the Medicare Advantage Plus plan from Empire BlueCross BlueShield on January 1, 2022. The webinars will review key operational processes such as determining eligibility and benefits, prior authorization requirements, and claims submissions to assist you in continuing to provide care for City of New York retirees. Please access the following invitation link to register for a webinar during the months of November, December, and January: https://empireblue.com/da/inline/pdf/ebscare-1086-21.pdf.
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 for Empire.
Effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub® as the electronic funds transfer (EFT) enrollment website for Empire providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users.
When you sign up for EFT through https://enrollsafe.payeehub.org, the new enrollment website, you’ll receive your payments up to seven days sooner than through the paper check method. Not only is receiving your payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.
EnrollSafe is safe, secure and available 24-hours a day
Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org to enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use https://enrollsafe.payeehub.org to update your account.
Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposit. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on the Availity* Portal. To access the ERA, log onto https://www.availity.com and use the Claims and Payments tab. Select Send and Receive EDI Files, then select Received Files Folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice through the Remittance Inquiry app.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (Empire) is offering Special Needs Plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. Some SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid, which include supplemental benefits such as hearing, dental, vision, and transportation to medical appointments. Some SNP plans include a card or catalog for purchasing over-the-counter items, but SNPs do not charge premiums.
SNP members benefit from a model of care (MOC) that is used by Empire to assess needs and coordinate care. Each member receives a comprehensive health risk assessment (HRA) within 90 days of enrollment and annually thereafter, which covers physical, behavioral, and functional needs, along with a comprehensive medication review. The HRA is then used to create a member care plan. Members with multiple or complex conditions are assigned a health plan case manager.
SNP HRAs, care plans, and case managers support members and their providers by helping identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments plus providing navigation and coordination of services across the Medicare and Medicaid programs.
Provider training required
Providers contracted for SNP plans are required to complete an annual training to keep up-to-date with plan benefits and requirements, including details on coordination of care and MOC elements. Every provider contracted for SNP is required to complete an attestation stating they have completed their annual training. These attestations are located at the end of the self-paced training document.
To take the self-paced training, please go to the MOC Provider Training link at https://www.availity.com.
How to access the Custom Learning Center on the Availity Portal:*
- Log in to the Availity Portal at https://www.availity.com.
- At the top of the Availity Portal, select Payer Spaces and select the appropriate payer.
- On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
- In the Custom Learning Center, select Required Training.
- Select Special Needs Plan and Model of Care Overview.
- Select Enroll.
- Select Start.
- Once the course is completed, select Attestation and complete.
Not registered for the Availity Portal?
Have your organization’s designated administrator register your organization for the Availity Portal.
- Visit https://www.availity.com to register.
- Select Register.
- Select your organization type.
- In the Registration wizard, follow the prompts to complete the registration for your organization.
See attached for a Q&A on Special Needs Plans.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Instead of faxing multiple pages of medical records for HEDIS® studies, use Empire BlueCross BlueShield (Empire)’s Remote EMR Access Service we offer to providers that allows us to access your EMR system directly to pull the documentation we need. Our Remote EMR Access Service helps reduce the time and costs associated with medical record retrieval while improving efficiency and lessening the impact on your office staff.
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 evidence related to the HEDIS® measures.
- We only view face sheets when there are demographic discrepancies.
- We exclude data related to hospice, long-term care, inpatient, and palliative care.
Let us help you! Getting started with Remote EMR Access is just one click away.
Download and complete this registration form and email it to us at Centralized_EMR_Team@anthem.com.
To learn more about our Remote EMR Access Service, view the Frequently Asked Questions below.
Q. How do you retrieve our medical records?
A. We access your EMR using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally, on our secure network drives.
Q. Is printing necessary? A. Yes. The NCQA audit requires print-to-file access.
Q. Is this process secure?A. Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Empire secure network drives.
Q. Why does Empire need full access to the entire medical record?A. 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 non-standard format, such as an in-office lab slip scanned into miscellaneous documents
Q. What information do I need to submit to use your Remote EMR Access Service?A. Complete the registration form that requests the following information:
- Practice/facility demographic information (e.g., address, National Provider ID, taxpayer identification numbers , etc.)
- EMR system information (e.g., type of EMR system, required access forms, access type – web based or VPN-to-VPN connection, special requirements needed for access, etc.)
- List of current providers/locations or a website for accessing this list. Also, if applicable, a list of providers affiliated with the group that are not in the EMR System.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (Effective 01/01/22)
Empire BlueCross BlueShield (Empire) allows reimbursement of sexually transmitted infection (STI) tests unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. We consider certain STI testing CPT® codes to be part of a laboratory panel grouping. When Empire receives a claim with two or more single tests laboratory procedure codes reported, we will bundle those two or more single tests into the comprehensive laboratory procedure code listed below.
Applicable single STI CPT codes:
- 87491: Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, amplified probe technique
- 87591: Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, amplified probe technique
- 87661: Infectious agent detection by nucleic acid (DNA or RNA); trichomonas vaginalis, amplified probe technique
Applicable comprehensive code:
- 87801: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique
Empire will reimburse the more comprehensive, multiple organism code for infectious agent detection by nucleic acid, amplified probe technique (CPT code 87801), when two or more single test CPT codes are billed separately by the same provider on the same date of service. Reimbursement will be made based on a single unit of CPT code 87801 regardless of the units billed for a single code. No modifiers will override the edit.
For additional information, please review the Sexually Transmitted Infections Testing — Professional reimbursement policy at https://www.empireblue.com/medicareprovider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective November 1, 2021, the Clinical Criteria ING-CC-0005 will include a trial and inadequate response or intolerance to two preferred hyaluronan agents in the Part B medical step therapy precertification review. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as-is current procedure). Step therapy will not apply for members who are actively receiving non-preferred medications listed below.
Clinical Criteria are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.
|
Clinical Criteria
|
Preferred drug(s)
|
Nonpreferred drug(s)
|
|
ING-CC-0005
|
Euflexxa (J7323)
Supartz FX (J7321)
Durolane (J7318)
Gelsyn-3 (J7328)
|
Including but not limited to:
· Gel-One (J7326)
· GenVisc 850 (J7320)
· Hymovis (J7322)
· Monovisc (J7327)
· Orthovisc (J7324)
· Synvisc/Synvisc One (J7325)
· TriVisc (J7329)
· Hyalgan/Visco-3 (J7321)
· Triluron (J7332)
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |