 Provider News New YorkSeptember 2022 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Register today for the Exploring the Intersection of Race and Disability forum hosted by Empire BlueCross BlueShield (Empire) and Motivo* for Empire providers on September 21, 2022.
Empire is committed to making healthcare simpler and reducing health disparities. We believe that continuing the discussion we started at our June 2022 event to deepen the conversation about the disability experience for people of is critically important. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Empire about the intersection of disability and race. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.
Wednesday, September 21, 2022
4 p.m. to 5:30 p.m. ET
Please register for this event by visiting this link.
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).
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.
FAQs
Who can become infected?
With this recent outbreak, monkeypox has spread through close, intimate contact with someone who has monkeypox. Many cases initially occurred in men who have sex with men. However, anyone can get monkeypox.
How dangerous is the disease?
Monkeypox virus belongs to 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.
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.
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.
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.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. According to the American Medical Association (AMA) Current Procedural Terminology (CPT ®) guidelines, a new patient is defined as “one who has not received any professional services (i.e., face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice) within the past three years.”
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after October 1, 2022, Empire BlueCross BlueShield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers that believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual or resubmit the claim with an established patient E/M.
If you have questions on this program, contact your contract manager or Provider Experience representative.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a reminder, when billing medical drug codes to Empire BlueCross BlueShield, include these three components:
- National Drug Code (NDC)
- Quantity
- Unit of measure
To prevent possible denial of the of the billed code, please ensure all three components are included in the claim.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Health Resources & Services Administration (HRSA) Women’s Preventive Services Guidelines recommend women receive at least one preventive care visit per year.
While many members may receive a standalone preventive care visit, well-women visits may also include prepregnancy, prenatal, postpartum, and interpregnancy visits. For members receiving prepregnancy, prenatal, postpartum, and/or interpregnancy care that is billed using a global maternity code (for example, CPT® 59400, 59510, 59610, 59618) or antepartum/postpartum codes (for example, CPT 59425, 59426, 59430), it is appropriate to submit a claim for a wellness visit (for example, CPT 99385, 99386, 99387, 99395, 99396, 99397) when recommended preventive care has been rendered for a member who has not received a wellness visit in the last year. This will help ensure recognition that recommended preventive services have been provided for our members.
Please note, wellness evaluation and management (E/M) codes should not be billed on the same day as global maternity or antepartum/postpartum codes. Providers should continue to verify eligibility and benefits for all members prior to rendering services.
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).
Effective July 1, 2022, Empire recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Empire contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims.
The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Empire for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.
The following Empire benefit plans are in scope for participation in HiH:
- Empire Commercial
- Medicare Advantage (Individual and Group)
- Medicare Advantage Special Needs plans, including Dual-Eligible Special Needs (D-SNP)
The following Empire plans are out of scope for participation in HiH:
Note:
Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Empire suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
Facility shall not bill Empire or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
Notify Empire immediately through the utilization management nurse assigned to the HiH case when:
- An applicable member is admitted to the HiH program
- A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Empire Agreement and/or as outlined in the applicable Empire provider manual.
We will continue to update billing guidance as these programs evolve.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Keeping your provider directory information current is key for members and your healthcare partners to engage with you seamlessly. Please review your information regularly and let us know if any of your information we show in our online directory has changed.
To update your information, use 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 Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Three things to do when you do not find your claim in Claim Status
We appreciate the positive feedback you have shared about the new Claim Status Send Attachment feature. This enhancement to the attachment process enables you to submit an attachment directly to your claim at https://www.availity.com* by simply selecting the new Send Attachment button. We want to keep that positive momentum by answering your questions about those times when you are not able to find your claim in the Claim Status application using Availity Essentials. Here are a few suggestions:
- Double check your search information. Is the member information entered correctly? Many times, it is as simple as double checking the basic information needed to search for the claim.
- Do you have a claim number? If we have requested additional information to process your claim, the claim number will be included in the letter to you. Use this claim number to search for your claim.
- If you have located your claim, but the Send Attachment feature is not displayed, we have a solution for you:
- From the Claims & Payment tab, select Attachments – New. This will take you to your Attachments Dashboard.
- From the Attachments Dashboard, select Send Attachment.
- From the dropdown, select Medical Attachment.
- Complete the form and use the Add Attachment button to upload your files.
- Select Send Attachments, and your documents will be attached to your claim.
Claims attachment learning opportunities
In collaboration with Availity Essentials, we have made it easy for you to learn when it is convenient for you. Through this on-demand webinar, learn how to submit claim attachments through Claim Status. Go here to access the course. If live webinars fit into your schedule, use go here to sign up today.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Beginning with date of services on or after December 1, 2022, Modifier FT is allowed for reimbursement on critical care codes 99291, 99292, 99468, 99469, 99471, 99472, 99475, and 99476.
Modifier FT was created by the Centers for Medicare & Medicaid Services (CMS) and is included in our Claims Impacting Adjudication list located in the Related Coding section of our Modifier Rules policy (professional).
Modifier FT is defined as an unrelated evaluation and management (E/M) visit during a postoperative period or on the same day as a procedure or another E/M visit. (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated).
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. In the December 2021 edition of Provider News, we announced that an update to our reimbursement policy titled Assistant at Surgery – Professional, effective for dates of service on or after March 1, 2022. The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
This policy follows the Centers for Medicare & Medicaid Services (CMS) guidelines for the codes designated as MPFS Assistant Surgery payment indicator 2 always requiring an assistant surgeon. Codes identified with MPFS Assistant Surgery payment indicators 0, 1, and 9 are not allowed for reimbursement.
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. In the December 2021 edition of Provider News, we announced that a new commercial reimbursement policy titled Modifier 66 Surgical Teams – Professional would be effective for dates of service on or after March 1, 2022. The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
Modifier 66: Surgical Teams - Professional
Under this reimbursement policy, Empire BlueCross BlueShield (Empire) allows the procedures eligible for surgical teams when billed with modifier 66.
Empire follows the Centers for Medicaid and Medicare Services (CMS) Medicare physician fee schedule (MPFS) team surgery payment indicators and will allow services requiring team surgery billed with CMS MPFS payment indicator 1 (sometimes) and 2 (always) and will deny services billed with the indicator 0 (never) and 9 (not applicable).
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. Effective October 1, 2022, Empire BlueCross BlueShield (Empire) and AIM Specialty Health ®* (AIM), a separate specialty benefits management company, will launch a new Back Pain Management Program for fully insured members, as further outlined below.
Empire has an existing relationship with AIM in the administration of other programs. Empire is excited to expand this relationship to include additional services. AIM works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.
What is the Back Pain Management Program?
In pursuit of the commitment to improve healthcare quality and costs, we have created a new voluntary Back Pain Management Program to help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.
The program will be utilizing predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.
Our member engagement process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors.
- Risk stratification to ensure the appropriate level of support is provided.
- Targeted outreach to members through our digital engagement platform, email, and calls.
- Customized education and support of provider treatments based on member’s specific needs.
- Education and support of services such as behavioral health as appropriate.
Who is included in this new program?
All fully insured members currently participating in AIM and Empire programs are included.
The following groups are excluded: Self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP).
The AIM Back Pain Program microsite helps you learn more and access helpful information and tools such as program information and FAQs.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Blue Cross and Blue Shield Service Benefit Plan, also known as the Federal Employee Program (FEP), is now requiring new information on claims that are required by OBRA93 law to be priced at the Medicare allowance. Members that are over 64 years old and do not have Medicare Part B coverage fall under the OBRA93 law for Medicare pricing. In order for us to obtain the Medicare pricing, the CMS 1500 claim must have a rendering provider ID submitted on the claim . Claims submitted without the rendering provider ID will deny for the following message on the remit and require the provider to resubmit with this required field.
Remit message: 339 NEED PROVIDER NAME & NPI IN ORDER TO DETERMINE MEDICARE FEE SCHEDULE
This claim submission requirement applies to Federal employee member claims only. A Federal member can be identified with an R followed by 8 digits (for example, Rxxxxxxxx).
If you have any questions, please contact FEP Customer Service at 800-522-5566.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Specialty pharmacy updates for Empire BlueCross BlueShield (Empire) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire’s Medical Specialty Drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health (AIM®*), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0217
|
Amvuttra™ (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere® (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on and after December 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-0217
|
Amvuttra (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
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 (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).*
The following Clinical Criteria documents were endorsed at the June 23, 2022, Clinical Criteria meeting. To access the Clinical Criteria information, please visit this link.
New Clinical Criteria effective July 6, 2022
The following Clinical Criteria is new:
- ING-CC-0217 Amvuttra (vutrisiran)
Revised Clinical Criteria effective July 25, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0015 Infertility and HCG Agents
- ING-CC-0041 Complement Inhibitors
- ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
- ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0150 Kymriah (tisagenlecleucel)
Revised Clinical Criteria effective July 25, 2022
The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0031 Intravitreal Corticosteroid Implants
- ING-CC-0049 Radicava (edaravone)
- ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
- ING-CC-0076 Nulojix (belatacept)
- ING-CC-0077 Palynziq (pegvaliase-pqpz)
- ING-CC-0136 Drug Dosage, Frequency, and Route of Administration
- ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use
- ING-CC-0163 Durysta (bimatoprost implant)
New Clinical Criteria effective December 1, 2022
The following Clinical Criteria is new:
- ING-CC-0218 Xipere (triamcinolone acetonide injectable suspension)
Revised Clinical Criteria effective December 1, 2022
The following Clinical Criteria was revised and might result in services that were previously covered but may now be found to be not medically necessary:
- ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective with dates of service on and after October 1, 2022, and in accordance with the IngenioRx* Pharmacy and Therapeutics (P&T) process, Empire BlueCross BlueShield will update its drug lists that support Commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Empire BlueCross BlueShield HealthPlus. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.
For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Summary: On February 25, 2022, and March 24, 2022, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus (Empire). These policies were developed, revised or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Please note:
- The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Empire only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
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Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
|
September 10, 2022
|
ING-CC-0214
|
Carvykti (ciltacabtagene autoleucel)
|
New
|
|
September 10, 2022
|
ING-CC-0125
|
Opdivo (nivolumab)
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Revised
|
|
September 10, 2022
|
ING-CC-0194
|
Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
|
Revised
|
|
September 10, 2022
|
ING-CC-0010
|
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
|
Revised
|
|
September 10, 2022
|
ING-CC-0072
|
Vascular Endothelial Growth Factor (VEGF) Inhibitors
|
Revised
|
|
September 10, 2022
|
ING-CC-0029
|
Dupixent (dupilumab)
|
Revised
|
|
September 10, 2022
|
ING-CC-0208
|
Adbry (tralokinumab)
|
Revised
|
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, 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. Step therapy review will apply upon precertification initiation or renewal in addition to the current medical necessity review of all drugs noted in the chart.
The Clinical Criteria are publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS codes
|
|
ING-CC-0166
|
Preferred
|
Kanjinti
|
Q5117
|
|
ING-CC-0166
|
Non-preferred
|
Herceptin
|
J9355
|
|
ING-CC-0166
|
Non-preferred
|
Herzuma
|
Q5113
|
|
ING-CC-0166
|
Non-preferred
|
Ogivri
|
Q5114
|
|
ING-CC-0166
|
Non-preferred
|
Ontruzant
|
Q5112
|
|
ING-CC-0166
|
Non-preferred
|
Trazimera
|
Q5116
|
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 BlueCross BlueShield.
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are three options for submitting attachments:
- Through the attachments dashboard inbox: From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
- Through the 275 attachment: Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
- Through the Availity.com application: From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
If you submit your claim through the Availity application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. A number of chronic diseases, including heart disease, cancer, and type 2 diabetes, are linked to alcohol use disorders (AUD).
Heart disease:1
Low alcohol consumption is associated with a reduced risk for cardiovascular disease (CVD), but higher amounts and binge drinking lead to a higher risk of CVD. Binge drinking and chronic heavy alcohol consumption is associated with a higher risk of hypertension. Alcohol leads to buildup of plaque in the arteries, disruptions in arterial function, oxidative stress throughout the body, and imbalances in hormones that control blood pressure regulation.
Heavy alcohol use is also associated with increased risk for coronary heart disease, stroke, peripheral arterial disease, and cardiomyopathy. It is suspected that the increase in blood pressure from heavy alcohol use plays a part in these increased risks. Alcohol also appears to contribute to arthrosclerosis and chronic inflammation, which follow the pathophysiologic process behind most CVD.
See Piano, 2017 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513687) for a more thorough examination of the increased risk of CVD from excess alcohol use; mechanisms of action; biomarkers; and considerations of genetic, socioeconomic, and racial factors.
Cancer:
An estimated 3.5% of cancer deaths in the United States are alcohol-related. Alcohol is a known human carcinogen.2 When consumed, ethanol breaks down into acetaldehyde, which is carcinogenic.
Alcohol consumption is linked to seven types of cancers.3 It raises the risk for cancer of the mouth, larynx, throat, and esophagus. Drinking and smoking together significantly increases this risk. Alcohol helps the harmful chemicals in tobacco to better infiltrate the cells and cause disease. Alcohol can also limit the cells’ ability to repair DNA damage from the chemicals in tobacco.
Regular, heavy alcohol use damages the liver and causes inflammation and scarring. This increases the risk of liver cancer. In addition, alcohol can raise estrogen levels, which is associated with a higher risk of breast cancer. Moderate drinkers have up to a one and a half times increased risk of ectal cancer. While the risk is increased for men and women, the evidence of this link is stronger in men.
Type 2 diabetes
Chronic use of alcohol is considered to be a potential risk factor for the development of type 2 diabetes mellitus (T2D).4 Like heart disease, low alcohol consumption decreases the risk of T2D, but chronic heavy alcohol use increases the risk. Alcohol disrupts glucose homeostasis in the body and is associated with insulin resistance.
In addition, alcohol affects excess caloric intake, pancreatitis, and impaired liver function. This affects blood glucose levels and causes hypoglycemia. Alcohol alters the brain’s ability to produce hunger hormones and increases food-seeking behaviors. Dysregulation of these hormones (specifically ghrelin and leptin) plays a part in T2D.
Heavy alcohol use can worsen symptoms in patients with T2D and cause hyper- and hypoglycemia.5 Alcohol-induced hypoglycemia can lead to serious neurological complications in T2D patients, which may or may not be reversible. It can also cause life-threatening ketoacidosis, and worsen diabetic neuropathy and retinopathy. Alcohol has serious interactions with some T2D medications including Chlorpropamide, Metformin, and Troglitazone.
If you need assistance connecting your patients to chronic disease or AUD treatment, please contact Empire BlueCross BlueShield HealthPlus at 800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On December 1, 2022, Empire BlueCross BlueShield prior authorization (PA) requirements will change for the following code. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code:
L6715 — Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement
Not all PA requirements are listed here. Detailed PA requirements are available to providers on the provider website.
Providers may also call Provider Services by referencing the number on the back of the patient’s member ID card for assistance with PA requirements.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Empire BlueCross BlueShield. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.
For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures 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. This communication applies to the Medicaid and Medicare Advantage programs from Empire BlueCross BlueShield.
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are three options for submitting attachments:
- Through the attachments dashboard inbox: From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
- Through the 275 attachment: Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
- Through the Availity.com application: From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
If you submit your claim through the Availity application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
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, 2022, the specialty Medicare part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare part B drugs
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C9098
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Carvykti (ciltacabtagene autoleucel)
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J3490
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Carvykti (ciltacabtagene autoleucel)
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J3590
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Carvykti (ciltacabtagene autoleucel)
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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. Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare Part B drugs
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J0172
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Aduhelm (aducanumab-avwa)
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. AIM Specialty Health®* (AIM) created new contact center phone numbers for Medicare providers to call for prior authorization requests. The new phone numbers are listed below.
Note: The old number is not available for requests after August 15, 2022, so please use this new number to submit new prior authorization AIM requests.
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Health plan
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Market
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New number
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Empire Blue Cross Blue Shield
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NY
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866-745-1784
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As always, the best way to reach AIM is to use the ProviderPortalSM. It is:
- Self-service.
- Available 24/7.
- Customizable with physician information.
- Easy to use and allows real-time determinations.
The ProviderPortal is a fast and efficient way to start a case. It also allows your team to:
- Check order status and view order history.
- Print/save PDF of order summary.
- Use multiple staff members to enter/view the practice’s orders.
- Increase payment certainty.
- Reference desk training and tutorials, including clinical criteria and CPT® lists.
If not already registered, your first step is to register your practice in the ProviderPortal at www.providerportal.com.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |