We understand that providing the information needed to process a claim can cause payment delays, and the manual methods associated with mailing letters and returning information non-digitally is costly and inefficient.

We’re changing that by implementing a new process: Digital Request for Additional Information (Digital RFAI), and we’re inviting you to participate.

Digital requests for additional information are 50% faster than returning documentation any other way — making it the most efficient way to receive and return information — resulting in faster claim payments. 

Participation in Digital RFAI is easy

1. Registration:
   • Your organization’s Availity* administrator will register for Medical Attachments:
     • This enables you to receive digital notices (instead of paper) and to attach the requested documents directly to your claim.
     • Ensure all of your billing NPIs/TINs are registered.
2. User roles:
   • Your Availity administrator will also update or add new users with these specific role assignments through Availity Essentials:
     • Claims Status
     • Medical Attachments
   • This enables the users to view the Availity Attachment Dashboard.
3. Ready to go:
   • After the registration and user roles are completed on Availity, the Digital RFAI process is ready to go. 
   • Requests will automatically appear on the Attachments Dashboard each morning (when documents are needed).

Additional support

You, your organization’s Availity administrator, or other members of your team may need additional support – and we’re to help:

• For Availity Administrators: Take this training to ensure your NPIs are registered properly. 
• For those sending attachments: Take this user training to learn about accessing notifications, sorting and filtering, and other enhancements that improve your experience. 

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partner. For additional resources, visit the Digital RFAI webpage or contact your Provider Relations Account Manager. 

Description/Approach 

Provider performance can vary widely in relation to efficiency and quality. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables. 

We will add a new sorting option on the Find Care tool for members to leverage when they are searching for a non-PCP specialist provider. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers will be listed in order of their total score, though no individual scores will appear within the tool or be visible to the covered patients. The Personalized Match Phase 1 algorithm will be based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options will still be available on Find Care for our members. Members should consider a variety of factors when making decisions for choosing a specialist provider to manage their care. 

We evaluate provider groups and individual providers annually, using updated quality and efficiency methodologies and data.

Continue reading the rest of this article

Digital Request for Additional Information (Digital RFAI) is the fastest and easiest way to get us the documents we need to process your claim. Now, it is even better! We’ve added filter, sort, and search features for greater productivity. 

New filtering functions are ideal for organizations where more than one person is responsible for submitting claim attachments. Another great feature: your filters are saved (locked) – so you can see your desired filter view each time you log on but easily clear them when your search criteria changes. 

We are committed to shared success and reporting is just another way we are giving Digital RFAI users a productivity boost. We’ve added reporting fields that can be used for both History and Inbox reports.

Fields available for History and Inbox reports

Expanded reporting fields are downloadable! Use the download option to meet your specific reporting requirements.

We’re here to help! 

Want to know more about receiving digital notifications for faster claims processing? Visit the Digital RFAI learning microsite or reach out to your Provider Relations Account Manager.

Starting mid-September, search for patient information in Availity Essentials* Eligibility and Benefits without having a member ID. We’ve updated and streamlined the process to eliminate the need for the member ID while maintaining the highest HIPAA standards. Easily search for patient eligibility and benefits details using the Patient Search option of patient last name, patient first name, date of birth, and patient zip code.

Find Eligibility and Benefits Inquiry on Availity’s top menu bar under Patient Registration. Once it becomes available, make sure to use the new search feature when you need to find member information and do not have access to the member ID.

Need the member ID for another capability in Availity Essentials? When you use the new search option in Eligibility and Benefits Inquiry and see the eligibility and benefits details, the member’s current ID details will be available and allow you to transact within other digital capabilities where the member ID is required. 

Watch for more information on the Availity Essentials home page under News and Announcements to notify you when this feature is available. 

Get access to Availity Essentials now

If you and your organization aren’t currently registered for Availity Essentials, now is the time to make that happen. Availity Essentials offers secure online access for working together and is free to our providers. To register, visit the availity.com Registration Information page.

In accordance with Chapter 645 of the Laws of 2005, the New York State Medicaid program does not cover prescription or physician administered drugs used for the treatment of sexual dysfunction (SD) or erectile dysfunction (ED). Additionally, Medicaid does not reimburse any supplies or procedures used to treat SD/ED for persons required to register as sex offenders. Providers must verify that Medicaid members receiving any procedures or supplies that may be used for these indications are not listed as registered sex offenders.

Medicaid Managed Care (MMC) plans

Prior to approving requests for any SD/ED related drugs, supplies, or procedures, MMC plans (including mainstream MMC plans, HIV Special Needs Plans [SNPs], and Health and Recovery Plan [HARP] programs) are required to submit requests for information regarding enrollee status on the sex offender registry to the New York State Department of Health through the Health Commerce System (HCS) Erectile Dysfunction Verification System (EDVS) each time there are requests for these services.

New York State Medicaid fee-for-service has compiled the following list of services used for the treatment of SD/ED:

* Please note: In the inpatient setting, alprostadil and papaverine may be covered for the treatment of a condition other than sexual or erectile dysfunction for which the drugs have been approved by the FDA. Additionally, physician-administered collagenase, clostridium histolyticum, and phentolamine mesylate may be covered for the treatment of a condition, other than sexual or erectile dysfunction, for which the drug has been approved by the FDA and prior approval has been received.

All the above codes need to be checked in the state system before they are reviewed for medical necessity.

The following services will be added to precertification for the effective dates listed below.

To obtain precertification, providers can access Availity Essentials* (Availity.com) or call Empire BlueCross BlueShield’s 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.

Effective December 29, 2023, Carelon Medical Benefits Management, Inc.,*  a separate company, will expand the Musculoskeletal Program to perform medical necessity/clinical appropriateness reviews for:

1. The requested site of service for certain spine, joint, and interventional pain procedures.
2. Monitored anesthesia or conscious sedation (MAC), when requested in conjunction with interventional pain codes.

This Musculoskeletal Program applies to fully insured members of Empire BlueCross BlueShield (Empire) as outlined below.

Please note, these reviews do not apply to procedures performed on an emergent basis.

Carelon Medical Benefits Management will use the following Clinical Guidelines when performing these reviews. The Clinical Criteria to be used can be found by accessing the links below: Clinical Appropriateness Guidelines Surgical Appropriate Use Criteria: Site of Service CG-MED-78: Anesthesia Services for Interventional Pain Management Procedures.

Site of care reviews

Carelon Medical Benefits Management will continue to manage the Musculoskeletal Program and level of care review. The Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review.

A subset of the Carelon Medical Benefits Management Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT^® codes requiring prior authorization for the Musculoskeletal Site of Care program is available on the Carelon Medical Benefits Management Musculoskeletal microsite.

MAC reviews

The codes that will be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. A complete list of CPT^® codes requiring prior authorization for the Monitored Anesthesia Care for Interventional Pain program is available on the Carelon Medical Benefits Management Musculoskeletal microsite. If you have a member in a current course of treatment for pain management where services were approved without reviewing the MAC, identify the member for us at the next request.

Site of care review may also apply if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center.

The anesthesiologist may determine that a member requires monitored anesthesia on the day of service. A retrospective review may be requested, or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC, and a detailed description of the procedure performed for Carelon Medical Benefits Management to determine coverage for the service as medically necessary.    

Members included in the program

All fully insured members currently participating in the Carelon Medical Benefits Management Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the Musculoskeletal Program to add to their members’ benefit package as of December 29, 2023. To determine if prior authorization for the Carelon Medical Benefits Management Musculoskeletal Program applies to an Empire member, contact the Provider Services phone number on the back of the member’s ID card.

The following members are excluded: Medicare Advantage (individual and group), Medicaid, Medicare, Medicare supplement, and the Federal Employee Program^® (FEP^®).

Prior authorization requirements

For services scheduled to begin on or after December 29, 2023, care providers must contact Carelon Medical Benefits Management to obtain prior authorization. Ordering and servicing care providers may begin contacting Carelon Medical Benefits Management on December 18, 2023.

Care providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access ProviderPortal directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. Initiating a request on ProviderPortal and entering all the requested clinical questions will allow you to receive an immediate determination.
• Access Carelon Medical Benefits Management via the Availity Essentials* platform at Availity.com.
• Call the Carelon Medical Benefits Management Contact Center toll-free number at 866-714-1107, Monday through Friday, 8 a.m. to 5 p.m.
• The Musculoskeletal Program microsite helps you learn more and access helpful information and tools such as order entry checklists.

Note: If a care provider office attempts to use the Interactive Care Reviewer (ICR) tool on the Availity Essentials platform to prior authorize an outpatient musculoskeletal case, ICR will produce a message referring the care provider to Carelon Medical Benefits Management (ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management).

Musculoskeletal Site of Care and MAC training webinars

We invite you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the Carelon Medical Benefits Management ProviderPortal. Go to the Musculoskeletal Program microsite to register for an upcoming webinar. If you have previously registered for other services managed by Carelon Medical Benefits Management, there is no need to register again.

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

For services beginning on December 1, 2023, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) for members of most Commercial plans¹ will be reviewed by Carelon Post-Acute Solutions, LLC (formerly myNEXUS [Carelon LLC]).² Through this program, Carelon LLC clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate environment.

With this program implementation, Empire BlueCross BlueShield will transition to Carelon LLC Clinical Appropriateness Guidelines. The guideline can be accessed here. 

Members included in the PAC Review Program

Local Commercial fully insured and ASO members. 

Members of the following products are excluded: National Accounts, HealthLink, California HMO, New York HMO, State of New York, City of New York, 32BJ, New York Hotel Trades, JAA, Blue Card Host, Federal Employee Program® (FEP®).  

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon LLC will begin receiving requests on Tuesday, November 28, 2023, for members whose anticipated discharge date is December 1, 2023, or after. 

Providers are encouraged to request authorization using NexLync. Go to the Carelon LLC website to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the Carelon LLC Provider Call Center at 833-431-0780 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday. 

To learn more about Carelon PAS and upcoming training webinars, visit PAC-IM Program - Carelon Post Acute Solutions (carelonmedicalbenefitsmanagement.com) or email PACproviderrelations@carelon.com.

If you have additional questions, please call the Carelon LLC Provider Call Center at 833-431-0780. 

Effective for dates of service on and after December 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.* (formerly AIM Specialty Health_®).

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon in one of several ways:

• Access Carelon’s ProviderPortal_SM directly at www.providerportal.com:
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access Carelon via the Availity Essentials* website at www.availity.com.

Note: This update does not apply to the Federal Employee Program^®_.

If you have any questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective September 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Empire BlueCross BlueShield HealthPlus for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

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

• Web: Once logged in to Availity Essentials* at https://availity.com
• Fax: 800-964-3627
• Phone: 800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://mediprovider.empireblue.com/new-york-empire-provider/communications/news-and-announcements on the Resources tab or, for contracted providers, by accessing Availity.com. Providers may also call Provider Services at 800-450-8753 for assistance with PA requirements.

Effective October 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Empire BlueCross BlueShield HealthPlus for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

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

• Web: Once logged in to Availity* at availity.com. 
• Fax: 800-964-3627
• Phone: 800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to providers on providerpublic.empireblue.com on the Resources tab or for contracted providers by accessing availity.com. Providers may also call Provider Services at 800-450-8753 for assistance with PA requirements.

Effective December 1, 2023, prior authorization (PA) requirements will change for the following code(s).  The medical code(s) listed below will require PA by Empire BlueCross BlueShield for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these 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(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on empireblue.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com.* Providers may also call the number on the back of the member’s ID card for assistance with PA requirements.

Beginning with dates of service on or after December 1, 2023, Empire BlueCross BlueShield will expand the current Documentation Standards for Episodes of Care — Professional reimbursement policy to apply to facility providers. This policy outlines how and what elements must be documented for an episode of care.

The policy will be retitled Documentation Standards for Episodes of Care — Professional and Facility.

For specific policy details, visit the reimbursement policy page, at empireblue.com.

Beginning with dates of service on or after December 1, 2023, Empire BlueCross BlueShield will update the Place of Service – Facility reimbursement policy to include professional services billed under revenue codes 960-983 expanded to 960-989. According to the policy, Evaluation & Management (E/M) services and other professional services:

• Must be billed on a CMS-1500 claim form; and
• Are not reimbursable if billed on a UB-04 claim form (excluding E/M services rendered in an emergency room and billed with emergency room revenue codes).

The policy will be retitled Facility Guidelines for Claims related to Professional Services – Facility.

For specific policy details, visit the reimbursement policy page at empireblue.com.

In the July 2023 edition of Provider News, Empire BlueCross BlueShield announced multiple updates to the Prolonged Services – Professional reimbursement policy effective October 1, 2023.  To clarify, the update to “remove language requiring providers to report start and stop times for reimbursement eligibility” was effective as of May 19, 2023.

For specific policy details, visit empireblue.com/provider/policies/reimbursement/.

Effective as of June 14, 2023, Empire BlueCross BlueShield updated the Documentation and Reporting Guidelines for Evaluation and Management (E/M) Services reimbursement policy to include the 2021 American Medical Association (AMA) CPT^® Level of Medical Decision Making (MDM) table to align with the 2021-2023 Centers for Medicare & Medicaid Services (CMS) and AMA-CPT code changes. This table will be listed under the policy section titled Selecting a Level of Medical Decision Making for Coding an E/M Service. When determining the level of E/M service using MDM, this table will be used instead of the 1995/1997 CMS risk tables and the Marshfield Clinic tables. 

Additional updates to this reimbursement policy are as follows:

• Documentation submitted in accordance with this reimbursement policy will remain subject to signature and other requirements as stated in the related Documentation for Episodes of Care reimbursement policy. Therefore, the policy was updated to include the following note: All documents are subject to the Documentation Requirements for Episodes of Care policy.
• The Related Coding section was expanded to include other E/M services, as defined in the policy. 

For specific policy details, visit the reimbursement policy page.

Oral health is essential to general health and well-being. Poor dental health can cause oral cancer, gum disease, tooth loss, bad breath, and dental decay. It can also lead to:

• Heart disease — Those with gum disease are two-times more likely to have or develop heart disease.¹
• Strokes and clots — Those with gum disease have an increased susceptibility of having a stroke and/or developing blood clots.¹
• Respiratory disease — Harmful bacteria from the mouth can serve as an agent for pneumonia and bronchitis.²
• Kidney disease — Harmful bacteria from poor oral hygiene can weaken kidneys.³
• Pancreas — Research suggests a significant association between gum disease and pancreatic cancer.⁴
• Diabetes — Gum disease disrupts the control of blood sugar. Gum disease can be more severe and take longer to heal for someone with diabetes.⁵
• Mental illness — There is an explicit link between mental health and oral health, including tooth loss due to gum disease and tooth decay. Those with mental illness often experience dental phobia, tooth erosion from eating disorders, and dry mouth from medications. This can be a reciprocal relationship.⁶
• Poor pregnancy outcomes — Nearly 65% to 75% of pregnant women have gingivitis (from changing hormones during pregnancy). If not treated, this can lead to poor pregnancy outcomes for mother and baby, including preterm birth and low birth weight.⁷

What you can do:

• Make it regular practice to ask your patients if they go to the dentist.
• Perform an oral inspection at every visit.
• Have dental provider resources readily available; our participating dental provider for Medicaid Managed Care and Child Health Plus members is Liberty Dental.*
• Help your patients consider the consequences of poor oral health (especially since the COVID-19 pandemic) by encouraging preventive dental visits at least once a year.
• Recognize social and cultural disparities that can contribute to poor oral health.
• Provide fluoride varnish for children in the primary care setting.⁸ This application is reimbursable to physicians and nurse practitioners with proper CPT^® coding.

If you have questions, 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.

The Empire BlueCross BlueShield (Empire) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by the Medical Specialty Drug Review team of Empire. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc.,* a separate company.

The following Clinical Criteria documents were endorsed at the June 12, 2023, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective December 1, 2023

The following Clinical Criteria are new:

•    CC-0241 Elfabrio (pegunigalsidase alfa-iwxj)

•    CC-0242 Epkinly (epcoritamab-bysp)

•    CC-0243 Vyjuvek (beremagene geperpavec)

Revised Clinical Criteria effective December 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:

•    CC-0015 Infertility and HCG Agents

•    CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications

•    CC-0062 Tumor Necrosis Factor Antagonists

•    CC-0177 Zilretta (triamcinolone acetonide extended-release)

Effective April 5, 2023, Sublocade^® can no longer be filled at Accredo Specialty Pharmacy.* Members currently filling through Accredo Specialty Pharmacy will need to switch to CVS Specialty Pharmacy.*   A member of the CVS Specialty Pharmacy Care team will be contacting prescribers to obtain a new prescription. Prescribers can contact CVS Specialty Pharmacy at 877-254-0015.

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 the Empire Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.^*, 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.

Including the National Drug Code (NDC) code on your claim may 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, 2023, 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 site of prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

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, 2023, 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.

Effective for dates of service on and after September 1, 2023, the following medication codes billed on medical claims will require prior authorization in accordance with the requirements of the current or new Clinical Criteria documents.

Please note, inclusion of a national drug code on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the following specific Clinical Criteria listed.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at 800-450-8753.

The following Part B medications from the current Clinical Criteria Guidelines are included in our medical step therapy precertification review process. 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 medications listed below. 

There are no clinical changes to Clinical Criteria CC-005, Hyaluronan Injections. Based on feedback, the table listing the preferred and non-preferred products has been updated to present the information in a more useful manner. The updated table identifies preferred alternatives based on injection series. 

Clinical Criteria Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

**This collateral ran originally in the July 1, 2023, newsletter and was also posted on the provider portal with an October 1, 2023, effective date. The new date of service will begin on November 1, 2023.** 

Effective for dates of service on and after November 1, 2023, 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.