 Provider News New YorkOctober 1, 2022 October 2022 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the August edition of Provider News, we announced Physician Office Lab (POL) updates to be effective October 1, 2022. Please be advised those updates are being postponed and any updates to the POL list will be communicated at a later date.
As a reminder, the Empire BlueCross BlueShield (Empire) POL list can be found online at empireblue.com/provider > Provider Forms & Guides > Physician Office Lab (POL) List.
Empire members must be referred to a participating laboratory for any lab services not included on the POL list. Claims submitted to Empire for physician office laboratory services not on the POL list will be denied and members cannot be balance billed.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Commercial and Medicare Advantage programs from Empire BlueCross BlueShield (Empire).
Care providers are a trusted resource for members when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.
Some care providers may have seen a message on their provider Explanation of Benefits (EOB) stating that Empire does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOB message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.
To aid in processing claims for the monkeypox and smallpox vaccine products, care providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:
- Product code (90611 or 90622)
- Applicable ICD-10-CM diagnosis code
- Administration code
More detail on codes and cost-sharing
Providers are encouraged to use:
- Product code 90611 for smallpox and monkeypox vaccine.
- Product code 90622 for vaccinia (smallpox) virus vaccine.
- Code 87593 for laboratory testing.
When billing the monkeypox and smallpox vaccine products, care providers should submit those codes with a $0.01 charge.
Cost-sharing for the vaccine is waived.
If you have any questions, contact the Provider Service number on the back of the member’s ID card. You can read more information on monkeypox here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Please refer to the attached list for services that will be added to precertification list for the effective dates noted below.
To obtain precertification, providers can access Availity* via empireblue.com/provider or call our Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.
Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.
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 asking you to review your online provider directory information on a regular basis to ensure it is correct. Access your information by visiting www.empireblue.com/provider, then under Provider Overview, choose Find Care.
Submit updates and corrections to your directory information using our online Provider Maintenance Form. Online update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
Once you submit the form, we will send you an email acknowledging receipt of your request.
The Consolidated Appropriations Act (CAA) contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. By reviewing your information regularly, you can help us ensure your online provider directory information is current.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Now open for learning!
Understanding how to use the many time saving applications on Availity Essentials* is important to working together digitally. We’ve developed a learning place just for that purpose - the Provider Learning Hub.
Using the Provider Learning Hub is the easiest and quickest way to access courses and learning guides about claim submission, attachments and status, eligibility and benefits, and more. Access the Provider Learning Hub from www.empireblue.com/provider.
These new and improved learning experiences apply to Availity Essentials* and electronic data interchange (EDI) transactions:
- Visit the Provider Learning Hub for short, easy-to-follow training videos with supporting resources — no username and password required.
- Handy filtering options make it easy to find what you are looking for.
- The Favorites folder lets you save courses for easy access later.
- Register once and on future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today!
Access the Provider Learning Hub today using this link or from www.empireblue.com/provider under Important Announcements on the home page.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Effective as of July 27, 2022, Empire BlueCross BlueShield combined the Three-Dimensional (3D) Radiology Services – Facility and Three-Dimensional (3D) Radiology Services – Professional policies into a single policy with no changes to the intent of the policy. The Three-Dimensional (3D) Radiology Services – Professional policy was updated to include the facility-specific language from the facility policy, and the title was changed to Three-Dimensional (3D) Radiology Services – Professional and Facility. As a result, the Three-Dimensional (3D) Radiology Services – Facility policy will be retired.
For specific policy details, visit the reimbursement policy page, at www.empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Beginning with dates of service on or after January 1, 2023, Empire BlueCross BlueShield will update the Related Coding section of the policy with the following:
- Added CPT code 43497 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent
For specific policy details, visit the reimbursement policy page at www.empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield HealthPlus (Empire) reimburses both capitated and fee-for-service contracted providers for flu vaccine services.
We are aligning our reimbursement policy with the New York State Department of Health’s communication regarding flu vaccine codes and will reimburse for the following CPT® codes:
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90630
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90672
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90685
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90694
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90656
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90673
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90686
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90756
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90658
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90674
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90687
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90662
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90682
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90688
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If you provided flu vaccine service to an Empire member prior to receipt of this notice and did not include the service on the claim, please submit a corrected claim ( not a new claim) with the applicable code(s) to receive both the additional reimbursement and the credit for the quality measure.
If you have questions about this communication or need assistance with any other item, call Provider Services at 800-450-8753. NYBCBS-CD-004829-22, NYBCBS-CD-038041-23 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective July 8, 2022, the Federal Employee Program (FEP) for Empire BlueCross BlueShield (Empire) began participating in a real-time provider chat option through Availity. The secure portal allows providers to seek real-time answers to questions about prior authorization, precertification requirements, status check, and more.
Currently, only Missouri and Georgia providers can access the chat capability for Federal members. Chat is available from 8 a.m. to 7 p.m. ET through the secure provider website found at www.availity.com. Select Payer Spaces, Empire, and access the chat through Chat with Payer.
Chat is one example of how FEP is using digital technology to improve the health care experience with the goal of saving valuable time.
With the success of the real-time chat option for Federal members, we will implementing additional states ranging in dates from October 2022 through the first quarter of 2023.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Commercial, Medicaid, and Medicare Advantage programs from Empire.
Our pharmacy benefit management partner, IngenioRx,* will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.
This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.
If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:
- IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
- IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.
These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.
When e-prescribing orders to the mail and specialty pharmacies:
- Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
- If searching by NPI (National Provider Identifier), the NPI will not change.
In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.
Keeping you well informed is essential and remains our top priority. We will continue to provide updates prior to January and throughout 2023.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Specialty pharmacy updates for Empire BlueCross BlueShield 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.
Inclusion of the National Drug Code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code.
Step therapy updates
Effective for dates of service on and after January 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Please note that infliximab agents are subject to step therapy today, and this is to notify of the changes in the preferred and nonpreferred products. Inflectra will become non-preferred and Avsola will become preferred as of January 1, 2023.
Access our Clinical Criteria to view the complete information for these step therapy updates.
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Clinical Criteria
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Status
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0062
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Preferred
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Avsola
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Q5121
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ING-CC-0062
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Preferred
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Infliximab Unbranded
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J1745
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ING-CC-0062
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Preferred
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Remicade
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J1745
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ING-CC-0062
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Non-preferred
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Inflectra
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Q5103
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ING-CC-0062
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Non-preferred
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Renflexis
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Q5104
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
The Empire BlueCross BlueShield pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by our Medical Specialty Drug Review team. Oncology drugs will be managed by AIM Specialty Health (AIM®).*
The following Clinical Criteria documents were endorsed at the August 19, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, please visit this link.
Revised Clinical Criteria effective August 30, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
Revised Clinical Criteria effective August 30, 2022
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 19, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0100 Istodax (romidepsin)
- ING-CC-0104 Levoleucovorin Agents
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0140 Zulresso (brexanolone)
- ING-CC-0142 Somatuline Depot (lanreotide)
- ING-CC-0180 Monjuvi (tafasitamab-cxix)
- ING-CC-0182 Iron Agents
- ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
- ING-CC-0188 Imcivree (setmelanotide)
- ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
- ING-CC-0216 Opdualag (nivolumab and relatlimab-rmbw)
Revised Clinical Criteria effective September 19, 2022
The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0001 Erythropoiesis Stimulating Agents
- ING-CC-0004 Repository Corticotropin Injection
- ING-CC-0008 Subcutaneous Hormonal Implants
- ING-CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
- ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
- ING-CC-0020 Tysabri (natalizumab)
- ING-CC-0027 Denosumab Agents
- ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
- ING-CC-0036 Naltrexone Implantable Pellets
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0044 Exondys 51 (eteplirsen)
- ING-CC-0139 Evenity (romosozumab-aqqg)
- ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)
- ING-CC-0152 Vyondys 53 (golodirsen)
- ING-CC-0156 Reblozyl (luspatercept)
- ING-CC-0171 Zepzelca (lurbinectedin)
- ING-CC-0172 Viltepso (viltolarsen)
- ING-CC-0174 Kesimpta (ofatumumab)
- ING-CC-0179 Blenrep (belantamab mafodotin-blmf)
- ING-CC-0189 Amondys 45 (casimersen)
- ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
- ING-CC-0193 Evkeeza (evinacumab)
- ING-CC-0197 Jemperli (dostarlimab-gxly)
- ING-CC-0200 Aduhelm (aducanumab-avwa)
- ING-CC-0202 Saphnelo (anifrolumab-fnia)
- ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
- ING-CC-0208 Adbry (tralokinumab)
- ING-CC-0209 Leqvio (inclisiran)
- ING-CC-0217 Amvuttra (vutrisiran)
Revised Clinical Criteria effective January 1, 2023
The following 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-0002 Colony Stimulating Factor Agents
- ING-CC-0028 Benlysta (belimumab)
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0034 Hereditary Angioedema Agents
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0058 Octreotide Agents
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0082 Onpattro (patisiran)
- ING-CC-0142 Somatuline Depot (lanreotide)
- ING-CC-0176 Beleodaq (belinostat)
- ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)
New Clinical Criteria effective January 1, 2023
The following Clinical Criteria is new:
- ING-CC-0219 Korsuva (difelikefalin acetate)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Visit the Drug Lists page 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 Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
Federal Employee Program (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 from Empire.
Effective January 1, 2023, Empire BlueCross BlueShield HealthPlus will be adding behavioral health benefits as part of New York State’s carve-in for Medicaid Advantage Plus members. We are offering webinars to help you understand the upcoming changes for the behavioral health carve-in of Medicaid Advantage Plus (MAP). The webinars will cover: MAP transition; case management and care coordination support; benefits, authorization, and utilization management overview; and claims. Details and dates of trainings will be made available in next month's newsletter.
Registration Links:
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We are carefully monitoring the recent outbreak of monkeypox infections in the U.S. and are working to support our members and our network care providers with information to help you respond appropriately in the context of your patient population.
The best source of up-to-date information is at the Centers for Disease Control and Prevention which has a dedicated monkeypox page for healthcare professionals.
In addition to resources for care providers, the CDC has developed educational materials for the public, available for free download online.
How does monkeypox spread?
Monkeypox does not spread easily between people without close contact. Person-to-person transmission is possible by skin-to-skin contact with body fluids or monkeypox sores, or respiratory droplets during prolonged face-to-face contact, and less likely through contaminated items such as bedding, clothing, or towels. Patients are contagious until the scabs heal and are replaced by new skin.
How dangerous is the disease?
Monkeypox virus belongs to the poxvirus family and infection is rarely fatal. Patients whose immune system is compromised are most at risk for severe disease, along with children younger than 8 years old, pregnant and breastfeeding people, and people with a history of atopic dermatitis or other active skin conditions.
What are monkeypox symptoms?
Patients often have a characteristic rash (well-circumscribed, firm, or hard macules evolving to vesicles or pustules) on a single site on the body. Patients may also present with a fever and muscle aches. The rash may start in the genital and perianal areas. The lesions are painful when they initially emerge, but can become itchy as they heal, and then go away after two to four weeks. Symptoms can be similar or occur at the same time as sexually transmitted infections.
Is there a monkeypox vaccine?
Yes, although at the time of this writing, availability is limited. Smallpox and monkeypox vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox, and vaccination after a monkeypox exposure may help prevent the disease or make it less severe. You can access the CDC’s vaccination updates online.
How can monkeypox be treated?
There are no treatments specifically for monkeypox virus infections. However, antiviral drugs and vaccines developed to protect against smallpox may be used to prevent and treat monkeypox virus infections.
Do I need to report a case of suspected monkeypox?
Yes, contact your state health department if you have a patient with monkeypox. They can help with testing and exposure precautions. Find your state health plan department online.
What are the behavioral health impacts of monkeypox?
Studies reporting psychiatric symptoms have indicated that the presence of anxiety, depression, or low mood is common among hospitalized patients with monkeypox infection. Care providers can help by listening with compassion, understanding underlying behavioral health concerns that may be heightened during isolation, and refer patients to the appropriate level of support following a monkeypox diagnosis.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate 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. In line with our commitment to participating practitioners and members, Empire BlueCross BlueShield HealthPlus has a Members’ Rights and Responsibilities section located within the provider manual. The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Review this section in your provider manual here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Managing illness can be a daunting task for our members. It’s not always easy for patients to understand test results, know how to obtain essential resources for treatment, or determine who to contact with questions and concerns. Anthem is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals available to support members, families, providers, and caregivers. The complex case management process leverages the experience and expertise of the Care Coordination team to educate and empower our members by increasing self-management skills. The complex case management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare. Members or caregivers can refer themselves or family members by calling the Member Services number located on their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us via phone or visiting our provider website. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. You can contact us by phone at 833-869-5890. Case management business hours are Monday to Friday from 8 a.m. to 5 p.m. Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NYBCBS-CD-003829-22-CPN3339 Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (Policy 21-001, effective 01/01/2022)
In the October 2021 edition of the provider newsletter, we announced that a new reimbursement policy titled Sexually Transmitted Infections Testing — Professional would be effective for dates of service on or after January 1, 2022. We have made a decision to retract this reimbursement policy.
If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website for up-to-date contact information or call Provider Services at 800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Medicaid and Medicare Advantage programs from Empire.
Effective January 1, 2023, Empire BlueCross BlueShield HealthPlus will be adding behavioral health benefits as part of New York State’s carve-in for Medicaid Advantage Plus members. We are offering webinars to help you understand the upcoming changes for the behavioral health carve-in of Medicaid Advantage Plus (MAP). The webinars will cover: MAP transition; case management and care coordination support; benefits, authorization, and utilization management overview; and claims. Details and dates of trainings will be made available in next month's newsletter.
Registration Links:
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The attached FAQ communication is designed to provide general guidance for questions related to Medicare telehealth services during the Coronavirus (COVID-19) Public Health Emergency (PHE). The PHE is ongoing and ever evolving; therefore, Empire BlueCross BlueShield (Empire) wants to support accurate and up-to-date information around legal and regulatory changes that may impact healthcare.
This FAQ is for informational purposes only and is intended to provide guidance regarding the changing landscape of Medicare telehealth. This guidance is not all-inclusive; it is intended to address frequently asked questions and common Medicare telehealth topics. The content included herein is not intended to be a substitute for the provisions of applicable statutes or regulations or other relevant guidance issued by CMS, as those items are subject to change from time-to-time.
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 October 1, 2022, updated step criteria for immunoglobulins found in Clinical Criteria document ING-CC-0003 has been implemented. The preferred product list is being expanded. Please refer to the Clinical Criteria page for more information.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. (Policy 21-001, effective 01/01/2022)
In the October 2021 edition of the provider newsletter, we announced that a new reimbursement policy titled Sexually Transmitted Infections Testing — Professional would be effective for dates of service on or after January 1, 2022. We have made a decision to retract this reimbursement policy.
If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website for up-to-date contact information or call Provider Services via the number on the back of members’ ID cards.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |