Download April 2017 In this issue Page

April 2017
In this issue
Administrative Updates

Introducing Patient360 – Get Quick and Easy Access to
your Empire Member Records

Remittance Inquiry Search Option Streamlined

Response Needed to the Annual Verification Process

Blue Priority Reminder

Transitioning our claims processing system

Billing Policy and Procedure Overview

Medical Record Retrieval

Integrated Care Model for plans purchased on the Health
Insurance Marketplace

ConditionCare Program Benefits Patients and Physicians

Clinical Practice and Preventive Health Guidelines online
Products & Programs

Prior Authorization for Genetic Testing effective July 1, 2017

Specialty Pharmacy Prior Authorization list expanding
effective July 1, 2017

Clinically Equivalent Agents

Clinical Guideline Informational Notices

Pharmacy information available on empireblue.com

Empire provides new or additional evidence considered
during an appeal

Health Insurance Exchange and Health Care Reform articles
are available online
Policy Updates

Medical Policy updates

Clinical Guideline updates

Corrections to the Clinical Guidelines Updates section of
the February 2017 Newsletter

Coding Updates

Review medical policy and clinical guidelines when referring
services to a facility

Facility Reimbursement Policy updates
State & Federal Programs

Coding Patient Services Reminders

Preventive service procedure codes updated for 2017

CMS releases new coding guidelines for 3D mammography

Comply with clinical information requests
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EBCBSNL 0417
State & Federal Programs continued

New G codes for home health agencies

New place of service code 02 for telehealth services

Complete OptiNet assessments to avoid line-item denials

Review high-risk medication reports

AccordantCare™ to provide support for Individual MA
members with HIV

Medicare Supplement – please wait 30 days from Medicare
remittance date before submitting another claim

Keep up with Medicare news

Behavioral Health Medication Management program

Primary Care Provider Fax Change Form Available

Genetic Testing services to require prior authorization

Additional information on ClaimCheck® upgrade to
ClaimsXten™

PAVE Provider Breakfast Forums & Webinars

New benefit for the Federal Employee Program®
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Administrative updates
Introducing Patient360 – Get Quick and Easy Access to your Empire Member Records
In mid April 2017 Patient360 will be offered on the Availity Web Portal. This online application lets you quickly retrieve
detailed records about your Empire BlueCross BlueShield (“Empire”) patients.
Patient360 will be replacing Patient Care Summary that you have been accessing through Eligibility and Benefits on the
Availity Web Portal. It will also replace Member Medical History Plus (MMH Plus).
What is Patient360?
Patient360 is a real-time dashboard that gives you a robust picture of a patient’s health and treatment history and will help
you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic
information, care summaries, claims details, authorization details, pharmacy information and care management related
activities.
With this level of detail at your fingertips to be able to:
Spot utilization and pharmacy patterns
Avoid service duplication
Identify care gaps and trends
Coordinate care more effectively
Reduce the number of communications needed between PCPs and case managers
Access to Patient360 on the Availity Web Portal
To access Patient360 on the Availity Web Portal users need to be assigned to the Patient360 Role which Availity
Administrators can locate within the Clinical Roles options. If a user already has the Patient Care Summary role they will
automatically be re-assigned to the Patient360 role.
You may choose one of the 2 options listed below to navigate to Patient360:
Option 1
Select Patient Registration from Availity’s top menu bar.

Choose Eligibility and Benefits

Complete the required fields on the Eligibility and Benefits screen

Select the Patient360 link on the member’s benefit screen

Enter the member information in the required fields
Option 2
Select Payer Spaces from Availity’s top menu bar

Choose the Empire BlueCross BlueShield / Empire BlueCross tile

Select Patient360 located on the Applications page

Enter the member information in the required fields
What if your organization is not registered on the Availity Web Portal?
Go to www.Availity.com

Select Register
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

Select Get Started
Complete the online registration form
What if you need assistance?
If you have questions about Patient360 please contact your local network representative.
If you have questions regarding Availity Web Portal registration please contact Availity Client Services at 1-800-282-4548.
Remittance Inquiry Search Option Streamlined. Check it out!
We’ve changed the Check/EFT search option to make it easier for you to find your remittances.
You have 2 search options:

Search by Check/EFT which now only requires a Tax ID and does not require an NPI.
Or

Search using a date range which does require both a Tax ID and NPI.
Here’s how to access your remittances from the Availity Web Portal:
From the Availity Web Portal home page, select Payer Spaces, next choose Empire BlueCross BlueShield (“Empire”) from
the list of payer options, and then select Remittance Inquiry.
Need an imaged copy of the remittance for your records?
Select the View Remittance link associated with each remit to access the imaged copy of the paper remittance. You will have
the option to print or save.
Don’t see this valuable tool when you log in to the Availity Web Portal?
Contact your Availity Administrator to request Claims Status access which includes Remittance Inquiry. If you do not know
who the administrators are for your organization, log in to Availity, go to your account and select Who controls my access?
Go ahead try the Remittance Inquiry application today and see for yourself how easy it is to retrieve your remits!
Response Needed to the Annual Verification Process
Empire is required by the State of New York and CMS to ensure that we are publishing accurate directory information for our
members in both our on-line and paper provider directories. However, this information is only as good as what is provided by
you, our physicians and practitioners. Empire is conducting the annual verifications of its demographic and participation
information. You should have received an email, fax, phone call, or letter from Empire or our representative LexisNexis
requesting that this information be confirmed.
If you have received a fax or email - Please take a moment to review the form and indicate any changes or if no changes
sign and either fax it back to Empire at 1-855-325-5456 or via return email.
It is important that you respond to these requests. A non-response will result in your practice not appearing as a participating
provider in either our online Provider Finder or our printed directories for all lines of business.
This means:

Potential new patients will not find you when they perform a search in our directory
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
Current patients will no longer see your name listed in our directory
If you have questions or have not received this information please contact your Network Management Consultant immediately
by calling 1-800-992-BLUE (2583) and selecting the following prompts.




Option 1: Medical Providers
Option 4: Updates and Other Information
Option1: Participation and Credentialing Information
Enter your zip code
Blue Priority Reminder
The Blue Priority Network is now available for Large and Small Groups. Members will have the prefix BPR for Large Group
and QBP for Small Group. See below for a sample Blue Priority ID card sample.
Transitioning our claims processing system
Empire is transforming health care to be more personal, more accessible and more affordable. This transformation includes
our ability to administer renewing clients on another Empire system — a system already experienced in processing millions
of claims a week. This transition only applies to Empire large group accounts – groups with over 100 members. Please ask
your patients for their new ID Card and be sure to use the toll-free number appearing on the new card.
Here’s an overview of changes:
Group Numbers
At renewal, groups will get new group numbers. The new group numbers will have ten alphanumeric characters comprised of
two main parts:
1. Case number for the new system. The first six positions include the group’s existing group number, which is referred
to as a “case number” on the new system.
2. Product and membership identifier. New group numbers will feature four additional alphanumeric characters that
identify the group’s membership structure. A group’s basic structure on the new system will be broken out by
product and member eligibility type such as “active,” “retiree,” “COBRA” or “Medicare.”
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Member ID Cards
At renewal, members will get new ID cards that reflect their 2016 benefit plan. It’s important for members to use their new
member ID card beginning on their 2017 effective date to make sure their claims are processed correctly and without delay.
Explanation of Benefits
Our new-look EOB makes it easier and faster for members to know what’s been paid by Empire and how much they owe the
provider.
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Billing Policy and Procedure Overview
All claims must be submitted in accordance with the requirements of the provider contract, applicable member’s contract, and
Empire’s Provider Manual. You may not seek payment for covered services from the member, except for any applicable visit
fees, co-payments, deductibles, coinsurance, or penalties as described in the member’s contract. Except for co-payments,
which may be collected at the time of service or discharge, you should not bill the member for any cost-sharing amounts until
he/she has received an explanation of benefits (EOB). In no event should you require a deposit from a member prior to
providing covered services to the member. Any administrative charges applied by physicians must be within Empire’s
contractual and policies guidelines and should be prominently displayed within the office and disclosed to members prior to
any services be rendered
Medical Record Retrieval
As a reminder, Verscend is the contracted vendor to gather medical records on behalf of BlueCross and/or BlueShield
companies. Blue Plans utilize Verscend’s services to retrieve medical records to support HEDIS, risk adjustment and
government required programs.
Verscend is an experienced healthcare analytics and services company and best-in-class supplier. They provide an efficient,
centralized process, to coordinate medical record requests on behalf of BlueCross and/or BlueShield companies across the
country and help reduce multiple requests for patient data.
As outlined in your contract, you are required to respond to requests in support of risk adjustment, HEDIS and other
government required activities within the requested timeframe. This includes requests from Verscend. Empire is working
diligently to ensure this process is followed.
For your convenience medical records may be submitted to Verscend in the following ways:

Uploading the record image to our secure portal at www.submitrecords.com
enter your password: "bcbsa89" and select the files to be uploaded.

Secure fax at 1.888.231.9601; or

If you are unable to return by fax or upload, you may mail records to:
Verscend
66 E. Wadsworth Park Dr.
Draper, UT 84020
HIPAA/Privacy
Verscend is contractually bound to preserve the confidentiality of health plan members’ protected health information (PHI)
obtained from medical records, in accordance with HIPAA regulations. Please note that patient-authorized information
releases are not required in order for you to comply with these requests for medical records.
Providers are permitted to disclose protected health information (PHI) to health plans without authorization from the patient
when both the provider and health plan had a relationship with the patient and the information relates to the relationship [45
CFR 164.506(c)(4)]. For more information regarding privacy rule language, please visit http://www.hhs.gov/ocr/privacy.
If you have questions please contact your Network Management Consultant immediately by calling 1-800-992-BLUE (2583)
and selecting the following prompts.

Option 1: Medical Providers
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


Option 4: Updates and Other Information
Option1: Participation and Credentialing Information
Enter your zip code
Integrated Care Model for plans purchased on the Health Insurance Marketplace benefits patients
and physicians
An Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the
exchange) the ability to have continuity of care with each care management case. A single Primary Care Nurse provides
case and disease assessment and management. This continuity provides opportunity for the member to get assistance
working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to
improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and
serves as an excellent adjunct to physician care.
The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes,
COPD, heart failure, asthma and coronary artery disease. Our nurse care managers are part of an interdisciplinary team of
clinicians and other resource professionals that are there to support members, families, primary care physicians and
caregivers.
Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In
order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to
understand the member’s plan of care and educate the member on options for their treatment plan.
Members or caregivers can refer themselves or family members by calling the number located in the grid below.
How do you contact Case Management?
CM Telephone Number
1-800-563-5909
CM Email Address
[email protected]
CM Business Hours
Mon –Thursday 8:00 a.m. till 9:00 (local
time)
Friday 8:00 a.m. till 8:00 (local time)
Saturday 9:00 a.m. till 5:30 local time
ConditionCare Program Benefits Patients and Physicians
Empire members have additional resources available to help them better manage chronic conditions.
The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD,
heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health
professionals such as dietitians, pharmacists and health educators work with members to help them understand their
condition(s), their doctor’s orders and how to become a better self-manager of their condition.
Engagement methods vary by the individual’s risk level but can include:

Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and
resources.

Round-the-clock phone access to registered nurses.

Guidance and support from Nurse Care Managers and other health professionals.
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Physician benefits:

Save time by answering patients’ general health questions and responding to concerns, freeing up valuable time for
the physician and their staff.

Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and
recommendations.

Inform the physician with updates and reports on the patient’s progress in the program.
Please visit empireblue.com to find more information about the program such as program guidelines, educational materials
and other resources. Our Patient Referral Form can be used to refer other patients you feel may benefit from our program.
If you have any questions or comments about the program, call 1-877-681-6694. Our nurses are available Monday-Friday,
8:00 a.m. to 9:00 p.m., and Saturday, 9:00 a.m. to 5:30 p.m.
Clinical Practice and Preventive Health Guidelines Available online
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted
nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our
website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are
reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research,.
All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To
access the guidelines, go to the "Provider" home page at empireblue.com. From there, select “Provider & Facility” > Enter >
Health & Wellness> Practice Guidelines.
Products & Programs
Prior Authorization for Genetic Testing effective July 1, 2017
Effective with dates of service on or after July 1, 2017, Empire will transition the medical necessity review of all genetic
testing services for local fully insured members to AIM Specialty Health®, a separate company. Additionally, this review will
now take place as a prior authorization review.
The medical policies and associated codes that will be reviewed by AIM for medical necessity are as follows:
Medical Policy #
Medical Policy Title
Codes
GENE.00001
Genetic Testing for Cancer Susceptibility
GENE.00002
Preimplantation Genetic Diagnosis Testing
81404, 81405, 81406, 81437,
81438, 81445, 81450, 81455,
81479
89290, 89291
GENE.00003
GENE.00004
Genetic Testing and Biochemical Markers for the Diagnosis
of Alzheimer's Disease
Janus Kinase 2 (JAK2)V617F Gene Mutation Assay
81401, 81405, 81406, 83520,
84999, S3852
81270, 81403
GENE.00005
BCR-ABL Mutation Analysis
81170, 81401
GENE.00006
Epidermal Growth Factor Receptor (EGFR) Testing
81235, 88365
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GENE.00007
Cardiac Ion Channel Genetic Testing
GENE.00008
Analysis of Fecal DNA for Colorectal Cancer Screening
GENE.00009
Gene-Based Tests for Screening, Detection and
Management of Prostate Cancer
Genotype Testing for Genetic Polymorphisms to Determine
Drug-Metabolizer Status
GENE.00010
81406, 81413, 81414, 81404,
81405, 81406, 81407, 81408,
S3861
81528, 81479
81313, 81479, 81599
GENE.00014
Analysis of KRAS Status
81225, 81479, 81381, 81226,
81400, 81401, 81227, 81350,
81355, G9143
81519, 0008M, 81599, 84999,
S3854
81200, 81209, 81220, 81221,
81222, 81223, 81224, 81241,
81242, 81251, 81252, 81253,
81254, 81255, 81256, 81257,
81290, 81330, 81412, S3841,
S3842, S3844, S3845,
S3846, S3849, S3853,
81403, 81404, 81405, 81406,
S3800, 81479, 81415, 81416,
81417, 81425, 81426, 81427
81275, 81276, 88363
GENE.00016
Gene Expression Profiling for Colorectal Cancer
81525, 81599, 84999
GENE.00017
Genetic Testing for Diagnosis and Management of
Hereditary Cardiomyopathies (including ARVD/C)
GENE.00018
GENE.00019
Gene Expression Profiling for Cancers of Unknown Primary
Site
BRAF Mutation Analysis
81403, 81405, 81406, 81407,
81408, 81439, 81479, S3865,
S3866
81406, 81504, 81540, 81599
GENE.00020
Gene Expression Profile Tests for Multiple Myeloma
81479, 81599
GENE.00021
81228, 81229, S3870, 81405
GENE.00022
Chromosomal Microarray Analysis (CMA) for
Developmental Delay, Autism Spectrum Disorder,
Intellectual Disability (Intellectual Developmental Disorder)
and Congenital Anomalies
In Vitro Companion Diagnostic Devices
GENE.00023
Gene Expression Profiling of Melanomas
Specific coding does not
apply
81599, 84999
GENE.00024
DNA-Based Testing for Adolescent Idiopathic Scoliosis
0004M
GENE.00025
Molecular Profiling for the Evaluation of Malignant Tumors
81425, 81445, 81450, 81455,
81479, 81599, 88363
GENE.00026
Cell-Free Fetal DNA-Based Prenatal Screening for Fetal
Aneuploidy
The Panexia™ Test for Oncologic Indications
81507, 0009M, 81420, 81479,
81599, 81422
81406, 81479
GENE.00011
GENE.00012
GENE.00027
April 2017
Gene Expression Profiling for Managing Breast Cancer
Treatment
Preconceptional or Prenatal Genetic Testing of a Parent or
Prospective Parent
81210, 88363, 81406
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GENE.00028
Genetic Testing for Colorectal Cancer Susceptibility
GENE.00029
Genetic Testing for Breast and/or Ovarian Cancer
Syndrome
GENE.00030
Genetic Testing for Endocrine Gland Cancer Susceptibility
GENE.00031
Genetic Testing for PTEN Hamartoma Tumor Syndrome
81288,
81295,
81299,
81319,
81201,
81406
81162,
81214,
81432,
81404,
81455,
81321,
GENE.00032
Molecular Marker Evaluation of Thyroid Nodules
81545, 81599
GENE.00033
Genetic Testing for Inherited Peripheral Neuropathies
GENE.00034
SensiGene® Fetal RhD Genotyping Test
81324, 81325, 81326, 81403,
81404, 81405, 81406, 81440,
81479
81403
GENE.00035
GENE.00036
Genetic Testing for TP53 Mutations (Li-Fraumeni
Syndrome)
Genetic Testing for Hereditary Pancreatitis
GENE.00037
Genetic Testing for Macular Degeneration
GENE.00038
Genetic Testing for Statin-Induced Myopathy
81222, 81223, 81224, 81401,
81404, 81479
81401, 81405, 81408, 81479,
81599
81400
GENE.00039
Genetic Testing for Frontotemporal Dementia (FTD)
81406, 81479
GENE.00040
Genetic Testing for CHARGE Syndrome
81403, 81407
GENE.00041
Short Tandem Repeat Analysis for Specimen Provenance
Testing
Genetic Testing for Cerebral Autosomal Dominant
Arteriopathy with Subcortical Infarcts and
Leukoencephalopathy (CADASIL) Syndrome
Genetic Testing of an Individual’s Genome for Inherited
Diseases
81479
GENE.00042
GENE.00043
81292,
81296,
81300,
81403,
81202,
81293,
81297,
81317,
81435,
81203,
81211,
81215,
81433,
81405,
81479
81322,
81212, 81213,
81216, 81217,
81445, 81455
S3840, 81445,
81323
81404, 81405, 81445, 81455
81406
81479,
81405,
81411,
81425,
81431,
81460,
81479,
S3800
81404
81599,
81406,
81415,
81426,
81434,
81465,
81493,
GENE.00044
Analysis of PIK3CA Status in Tumor Cells
GENE.00045
Detection and Quantification of Tumor DNA Using Next
Generation Sequencing in Lymphoid Cancers
81479, 81599
GENE.00046
Prothrombin G20210A (Factor II) Mutation Testing
81240
GENE.00047
Methylenetetrahydrofolate Reductase Mutation Testing
81291
April 2017
81294,
81298,
81318,
81436,
81401,
81403,
81408,
81416,
81427,
81440,
81470,
81506,
81404,
81410,
81417,
81430,
81442,
81471,
81599,
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Beginning July 1, 2017, please submit genetic testing prior authorization requests to AIM through one of the following ways:
Access AIM ProviderPortalSM 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.
Access AIM via the Availity Web Portal at availity.com
Call the AIM Contact Center toll-free number: 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
To find more information about genetic testing prior authorization at AIM please go to www.aimprovider.com/genetic testing/
The program applies to local Empire fully insured members only.
This program excludes the following: Medicare, Medicaid, FEP, Labor & Trust, National Accounts and Local ASO.
For further questions regarding prior authorization requirements please contact the provider service number on the back of
your patient’s ID card.
Empire will be expanding the Specialty Pharmacy Prior Authorization list effective July 1, 2017
Listed below are specialty pharmacy codes from new or current Clinical UM Guidelines that will be added to our existing preservice review process effective July 1, 2017.
Prior Authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM®), a
separate company administering the program on behalf of Empire.
Medical Policy or Clinical
Guideline
Code
Drug
Comments
DRUG.00104
J3490
Spinraza
New Medical Policy
Effective Date
July 1, 2017
Ordering physicians should submit a Prior Authorization request for these additional services starting July 1,2017 or after to
AIM through the AIM ProviderPortalSM (available 24/7 to process orders in real-time), through the Availity Web Portal or by
calling the AIM call center at 1-877-430-2288, 8:00 a.m. – 6:00 p.m. ET
The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on Empire’s web site at
empireblue.com > Select Provider & Facilities > Medical Policy > Click on the link titled “Clinical UM Guidelines adopted by
Empire”.
This program applies to local Empire members who have specialty pharmacy services medically managed by AIM Specialty
Health. The expanded program does not apply to the following plans: Medicare Advantage, Medicaid, Medicare Supplement,
and Federal Employee Program (FEP).
Determine if Prior Authorization is needed for an Empire member by clicking your state’s “Medical Policy,” link at
empireblue.com or by calling the precertification phone number printed on the back of the member’s ID card.
Note: Retrospective requests received more than 2 business days after the date of service will not be accepted by AIM for
Prior Authorization review. Any post-service clinical review would be handled by Empire according to the terms of the
applicable health benefit plan and/or provider agreement.
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Clinically Equivalent Agents
As we previously communicated in the February 2017 edition of Network Update, Empire has selected Remicade (infliximab)
to be the infliximab of choice and the clinically equivalent agent over Inflectra (Infliximab-dyyb). Synvisc, Synvisc One,
Orthovisc, and Monovisc have been selected as the clinically equivalent Hyaluronic Acid agents of choice.
Please note that the revised effective implementation date is June 1, 2017 for CG.DRUG.64 and CG.DRUG.29.
Medical Policies and Clinical Guidelines that have been updated to include the requirement of a clinically equivalent
treatment are included in the chart below. Some benefit plans require the use of clinically equivalent agents, therefore when
prescribing a product in these categories, please consider using these agents.
Policy
Impacted Products
Clinically Equivalent/Cost
Effective Products
Remicade®
Effective Date
CG.DRIG.64; FDA-Approved
Biosimilar Products
*CG.Drug.29
Inflectra®
Euflexxa®,Gel-One®,
GelSyn®,Genvisc 850®,
Hyalgan®,Hymovis®,Supartz®
Monovisc®, Orthovisc®,
Synvisc®,Synvisc One®
June 1, 2017
DRUG.00017 Hyaluronan
injections for indications in joints
other than the knee
Euflexxa®,Gel-One®,
GelSyn®,Genvisc 850®,
Hyalgan®,Hymovis®,Supartz®
Monovisc®, Orthovisc®,
Synvisc®,Synvisc One®
July 1, 2017
June 1, 2017
*CG.DRUG.29 is for clinically equivalent agents only.
For more information on the Empire Medical Policy and Clinical UM guidelines and dosing guidelines refer to the complete
list of our Medical Policies and Clinical UM Guidelines on empireblue.com.
Clinical Guideline Informational Notices
Archived Clinical Guideline Number Effective 12-28-2016
(The following guideline number has been archived.)

CG-DRUG-15 - Gonadotropin Releasing Hormone Analogs [Note: Content of CG-DRUG-15 transferred to new
clinical UM guidelines CG-DRUG-60 Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic
Indications and CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic
Indications. Only CG-DRUG-61 has been adopted at this time].
Updated Biosimilar Product Information
Biosimilar products are now addressed in CG-DRUG-64 (effective 11-17-16). The clinical indications have not changed.
Pharmacy information available on empireblue.com
For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes,
prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management
methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain
drugs, visit http://www.anthem.com/pharmacyinformation. The drug list is reviewed and updates are posted to the web site
quarterly (the first of the month for January, April, July and October).
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To locate “Marketplace Select Formulary” and pharmacy information, go to Customer Support, select your state, Download
Forms and choose “Select Drug List.” For State-sponsored Business, visit SSB Pharmacy Information. Website links for the
Federal Employee Program formulary Basic and Standard Options are:
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Basic Option: https://www.caremark.com/portal/asset/z6500_drug_list807.pdf;
Standard Option: https://www.caremark.com/portal/asset/z6500_drug_list.pdf.
This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy Policy updates have been added to the FEP Medical Policy Manual and may be accessed at www.fepblue.org
> Benefit Plans > Brochures and Forms > Medical Policies.
Empire provides new or additional evidence considered during an appeal
The Department of Labor (DOL), Health and Human Services (HHS) and the Treasury published final ACA Market Reform
regulations. Under the rule, issuers must automatically provide impacted members (free of charge) a copy of any new or
additional evidence considered in conjunction with the appeal of a claim. This information must be provided in advance of a
final adverse benefit determination.
Please be advised, in accordance with the regulation, Empire will send new or additional evidence to impacted
members. This includes any information providers submit that is used in decision making for a grievance or appeal request.
Health Insurance Exchange and Health Care Reform articles are available online
We invite you to visit our website, empireblue.com to learn about the many ways health care reform and the health
insurance exchange may impact you.
To view the latest articles on health care reform and/or health insurance exchange, and all archived articles, go to
empireblue.com , select the Provider link in the top center of the page, and click Enter. From the Provider Home , select the
link titled Health Care Reform Updates and Notifications or Health Insurance Exchange Information.
Policy updates
These updates list the new and/or revised Empire medical policies, clinical guidelines and reimbursement policies. The
implementation date for each policy or guideline is noted for each section. Implementation of the new or revised medical
policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified
implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the
changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or
guideline, the policy or guideline will govern.
Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take
precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and
must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the
services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates
that may have been issued by Empire. Please include this update with your Provider Manual for future reference.
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Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Empire’s medical policies and clinical guidelines can be found at empireblue.com.
Medical Policy Updates
New Medical Policy Effective 01-20-2017
(The following policy is new and determined to not have significant changes.)
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DRUG.00104 - Nusinersen (SPINRAZA™)
Revised Medical Policies Effective 02-16-2017
(The following policies were revised to expand medical necessity indications or criteria.)
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DRUG.00068 - Vedolizumab (Entyvio®)
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SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Revised Medical Policies Effective 02-16-2017
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
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DRUG.00006 - Botulinum Toxin
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DRUG.00017 - Hyaluronan Injections in Joints Other than the Knee
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DRUG.00104 - Nusinersen (SPINRAZA™)
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OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
Archived Medical Policy Effective 02-20-2017
(The following policy has been archived for dates of service on or after 02-20-2017.)
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RAD.00060 - Digital Breast Tomosynthesis
Revised Medical Policy Effective 03-06-2017
(The following policy was revised and had no significant changes to the policy position or criteria.)
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DRUG.00077 - Monoclonal Antibodies to Interleukin-17A
New Medical Policy Effective 03-29-2017
(The following policy is new and determined to not have significant changes.)
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SURG.00146 - Extracorporeal Carbon Dioxide Removal
Revised Medical Policy Effective 03-29-2017
(The following policy was revised to expand medical necessity indications or criteria.)
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SURG.00127 - Sacroiliac Joint Fusion
Revised Medical Policies Effective 03-29-2017
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
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ADMIN.00001 - Medical Policy Formation
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ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
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BEH.00001 - Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid
Detoxification
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BEH.00004 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
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DME.00012 - Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and
Intrapulmonary Percussive Ventilation
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DME.00025 - Self-Operated Spinal Unloading Devices
DME.00035 - Electric Tumor Treatment Field (TTF)
DRUG.00004 - Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial
Hypertension
DRUG.00009 - Growth Hormone
DRUG.00013 - Administration of Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
DRUG.00027 - Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain
DRUG.00044 - Belimumab (Benlysta®)
DRUG.00045 - Tesamorelin (Egrifta®)
DRUG.00054 - Ocriplasmin (Jetrea®) Intravitreal Injection Treatment
DRUG.00074 - Alemtuzumab (Lemtrada®)
DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
DRUG.00080 - Monoclonal Antibodies for the Treatment of Eosinophilic Asthma
DRUG.00081 - Eteplirsen (Exondys 51™)
DRUG.00092 - Buprenorphine Implant (Probuphine®)
GENE.00007 - Cardiac Ion Channel Genetic Testing
GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
GENE.00012 - Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent
GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
GENE.00034 - SensiGene® Fetal RhD Genotyping Test
GENE.00036 - Genetic Testing for Hereditary Pancreatitis
GENE.00037 - Genetic Testing for Macular Degeneration
GENE.00039 - Genetic Testing for Frontotemporal Dementia (FTD)
GENE.00040 - Genetic Testing for CHARGE Syndrome
GENE.00046 - Prothrombin G20210A (Factor II) Mutation Testing
LAB.00024 - Immune Cell Function Assay
LAB.00029 - Rupture of Membranes (ROM) Testing in Pregnancy
LAB.00030 - Measurement of Serum Measurement of Serum Concentrations of Tumor Necrosis Factor Antagonist
Drugs and Antibodies to Tumor Necrosis Factor Antagonist Drugs
MED.00002 - Selected Sleep Testing Services
MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
MED.00041 - Microvolt T-Wave Alternans
MED.00065 - Hepatic Activation Therapy
MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
MED.00077 - In-Vivo Analysis of Gastrointestinal Lesions
MED.00091 - Rhinophototherapy
MED.00092 - Automated Nerve Conduction Testing
MED.00097 - Neural Therapy
MED.00100 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue
Grafting
MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
MED.00116 - Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
RAD.00029 - CT Colonography (Virtual Colonoscopy) for Colorectal Cancer
RAD.00051 - Functional Magnetic Resonance Imaging
RAD.00053 - Cervical and Thoracic Discography
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RAD.00055 - Magnetic Resonance Angiography of the Spinal Canal
RAD.00065 - Radiostereometric Analysis
SURG.00001 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
SURG.00007 - Vagus Nerve Stimulation
SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue
Grafting
SURG.00019 - Transmyocardial Revascularization
SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
SURG.00046 - Gastric Electrical Stimulation
SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
SURG.00052 - Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET],
Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
SURG.00086 - Reduction Mammaplasty
SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
SURG.00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
SURG.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus
SURG.00108 - Endothelial Keratoplasty
SURG.00109 - Surgical Treatment of Femoroacetabular Impingement Syndrome
SURG.00115 - Keratoprosthesis
SURG.00117 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and
Fecal Incontinence; Urinary Retention
SURG.00119 - Endobronchial Valve Devices
SURG.00121 - Transcatheter Heart Valve Procedures
SURG.00123 - Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
SURG.00130 - Annulus Closure After Discectomy
SURG.00136 - Intraocular Telescope
SURG.00138 - Laser Treatment of Onychomycosis
SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
TRANS.00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
TRANS.00009 - Lung and Lobar Transplantation
TRANS.00010 - Autologous and Allogeneic Pancreatic Islet Cell Transplantation
TRANS.00015 - Meniscal Allograft Transplantation of the Knee
TRANS.00026 - Heart/Lung Transplantation
New Medical Policies Effective 07-01-2017
(The policies below were created and might result in services that were previously covered but may now be found to be
either not medically necessary and/or investigational.)
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LAB.00034 - Serological Antibody Testing for Helicobacter Pylori
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SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
Revised Medical Policies Effective 07-01-2017
(The policies below were revised and might result in services that were previously covered but may now be found to be either
not medically necessary and/or investigational.)
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DRUG.00090 - Bezlotoxumab (ZINPLAVA™)
GENE.00008 - Analysis of Fecal DNA for Colorectal Cancer Screening
SURG.00010 - Treatments for Urinary Incontinence
Clinical Guidelines updates
Revised Clinical Guidelines Effective 02-16-2017
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
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CG-DRUG-28 - Alglucosidase alfa (Lumizyme®)
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CG-SURG-27 - Sex Reassignment Surgery
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CG-SURG-43 - Knee Arthroscopy
Revised Clinical Guideline Effective 02-16-2017
(The following adopted guideline was reviewed and had no significant changes to the policy position or criteria.)
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CG-DRUG-64 - FDA-Approved Biosimilar Products
Revised Clinical Guidelines Effective 03-29-2017
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
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CG-ANC-04 - Ambulance Services: Air and Water
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CG-DME-10 - Durable Medical Equipment
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CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, With or Without Power Seating
Systems and Power Operated Vehicles (POVs)
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CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
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CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use
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CG-DRUG-16 - White Blood Cell Growth Factors
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CG-DRUG-43 - Natalizumab (Tysabri®)
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CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices
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CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
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CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
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CG-SURG-24 - Functional Endoscopic Sinus Surgery (FESS)
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CG-SURG-47 - Surgical Interventions for Scoliosis and Spinal Deformity
Revised Clinical Guidelines Effective 07-01-2017
(The following adopted guidelines were revised and might result in services that were previously covered but may now be
found to be not medically necessary.)
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CG-BEH-04 - Substance-Related and Addictive Disorder Treatment
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CG-BEH-05 - Eating and Feeding Disorder Treatment
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CG-MED-19 - Custodial Care
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CG-REHAB-04 - Physical Therapy
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CG-REHAB-05 - Occupational Therapy
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CG-REHAB-06 - Speech-Language Pathology Services (NOTE: Applicable to National Accounts only)
Corrections to the Clinical Guidelines Updates section of the February 2017 Newsletter
In the February 2017 editioin of Network Update, we advised that CG-DRUG-29 Hyaluronan Injections in the Knee would be
adopted effective May 1, 2017. We wanted to advise that this clinical guideline policy will be adopted effective June 1, 2017.
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Coding Updates
As a result of coding updates in the claims system, the claim system edits for the policies listed below will be revised. This
will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets
medical necessity criteria. As a result, these coding updates may result in a not medically necessary and/or investigational
determination.
Effective July 15, 2017, we will be implementing coding updates in the claims system for the following policy listed below
which may result in investigational/not medically necessary determinations for certain services.
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DRUG.00104 - Nusinersen (SPINRAZA™)
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GENE.00007 – Cardiac Ion Channel Genetic Testing
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SURG.00001 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
Review medical policy and clinical guidelines when referring services to a facility
In past issues of Network Update, we reminded that you should review Empire’s on-line medical policies and clinical
guidelines when referring members for services at a facility that are considered not medically necessary or investigational.
Services which are determined to be not medically necessary are the liability of the rendering provider pursuant to Empire’s
participating provider agreements unless a waiver is signed by the member satisfying certain criteria.
Effective July 15, 2017, we will be implementing coding updates in the claims system for the following policy listed below
which may result in investigational/not medically necessary determinations for certain services.
SURG.00037 - Treatment of Varicose Veins (Lower Extremities)
As a reminder, Empire’s medical policies and clinical guidelines are available online at empireblue.com. You may search by
procedure code, diagnosis code, clinical guideline or medical policy number or name. Please be sure to review medical
policy and clinical guidelines when referring services to a facility to ensure services are consistent with medical policy.
Reimbursement Policy updates
Anesthesia Services, Bundled Services and Supplies, and Modifiers 59, XE, XP, XS, and XU
We have updated our Anesthesia Services, Bundled Services and Supplies, and Modifiers 59, XE, XP, XS, and XU policies to
reflect coding changes to imaging guidance and spinal injections based on January 1, 2017 Current Procedural Terminology
(CPT®) code additions and deletions however these updates do not cause significant changes to the policies’ position or
criteria.
Claim Editing Overview and Frequency Editing
We are updating our Claim Editing Overview and Frequency Editing reimbursement policies to further clarify our frequency
editing guidelines will apply per day unit frequency maximums based on the CPT/HCPCS codes listed on the CMS Medically
Unlikely Edit (MUE) listing that have a per day MUE Adjudication Indicator (MAI) of “2.” Modifiers will not override these
frequency limits.
Frequency Editing
CPT codes 95925, 95926, 95938, and 95927 (short-latency somatosensory evoked potential study, stimulation of any/all
peripheral nerves or skin sites, recording from the central nervous system...) and 95928, 95929, and 95939 (central motor
evoked potential study (transcranial motor stimulation)...) are currently limited to once per date of service. Based on the
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indication of plurality within each code’s description, beginning with claims processed on or after May 22, 2017, modifiers will
not override the frequency limit of one per date of service on each of these codes.
CPT code 96900 (actinotherapy (ultraviolet light)) is currently limited to once per date of service. The August 2006 CPT
Assistant states, "Code 96900 is reported once per session... regardless of the number of anatomical areas treated.”
Therefore, beginning with claims processed on or after May 22, 2017 modifiers will not override the frequency limit of one per
date of service.
In addition, CPT code 87483(infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen...
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or
subtypes, 12-25 targets) will have a unit limit of 1 per date of service for claims processed on or after May 22, 2017.
Modifiers will not override this frequency limit edit.
Injection & Infusion Administration and Related Services & Supplies
Hydration, therapeutic, prophylactic, and diagnostic injections and infusions are used for the administration of fluids and
medications. Empire considers such injection and infusion services to be an integral component to the performance of
procedural services that require the use of injection or infusion services to complete the procedure. Therefore, we are
updating our policy to clarify our current edits do not allow separate reimbursement for hydration, therapeutic, prophylactic,
and diagnostic injections and infusions when reported with procedures that inherently include injection or infusion services to
complete the procedure (e.g. 96360-96361 (hydration infusion) will not be eligible for separate reimbursement when reported
with 92242 (fluorescein angiography and indocyanine-green angiography)).
Laboratory & Venipuncture Services and Modifier Rules
We are updating our policies to reflect that modifier 91 (repeat clinical diagnostic laboratory test) will not override our
bundling edit for component codes for “Organ and Disease-Oriented Panels.” This edit will be effective for claims processed
on or after May 22, 2017.
Modifier Rules
We are adding modifiers Q5 (service furnished by a substitute physician under a reciprocal billing arrangement) and Q6
(service furnished by a locum tenens physician) to our Modifier Rules policy. These modifiers are informational only and
have no effect on the maximum allowed amount of the reported procedure code.
Unit Frequency Maximums for Drugs and Biologic Substances
Beginning with dates of service on or after July 1, 2017, HCPCS code J9351 (injection, topotecan, 0.1 mg) will have a
frequency limit of 40 units per date of service. Modifiers will not override the frequency limit edit
Review of Reimbursement Policies
The following professional reimbursement policies received a review and may have word changes or clarifications however
they do not have significant changes to the policy position or criteria:
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Cancer Treatment Planning and Care Coordination
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Surgical Pathology & Related Prostate Needle Biopsy
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Screening Services with Related Evaluation & Management Services
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State & Federal updates
Medicare Advantage
Coding Patient Services Reminders
To help ensure your patients and our members receive their medical care in a timely fashion, we would like to remind you of
important things to keep in mind when submitting CPT codes for requested services:
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Ensure the CPT code requested is the service that the physician/provider details in the medical record.
Review appropriate coding and Medicare guidelines to ensure service is a covered service and that the code is a
valid code for that year.
If a code that is requested does not match the intended service, please be prepared to correct the error and
resubmit the request.
Empire relies on the information submitted from the medical record to make its determinations on your requests. It is
important that all relevant information to the members requested service be submitted.
Providers requesting authorization for services based on incorrectly documented CPT/HCPCS codes may receive avoidable
denial notices where the code/service is found not medically necessary or non-covered.
Preventive service procedure codes updated for 2017
Preventive service procedure codes have been updated. Please be sure to file claims with the new codes according to the
dates of service applicable.
Abdominal Aortic Aneurysms
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Effective Jan. 1, 2017, 76706 will replace G0389 for Abdominal Aortic Aneurysms (AAA)
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G0389 is used for services furnished prior to 01/01/2017.
New flu vaccines –Medicare preventive benefit – Part B immunizations
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90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic
free, 0.5 mL dosage, for intramuscular use
– This new flu vaccine code can be used for dates of service on or after Aug. 1, 2016.
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90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only,
preservative and antibiotic free, for intramuscular use
– Currently, this new flu vaccine has not received FDA approval therefore this flu vaccine will be denied. Once
approved by the FDA, this vaccine will be a covered Medicare Part B Immunization.
Smoking and tobacco cessation
Effective Oct. 1, 2016, G0436 and G0437 are no longer valid codes for smoking and tobacco cessation counseling
services Beginning with dates of service on or after Oct. 1, 2016, CPT codes 99406 and 99407 should be used to report
smoking and tobacco cessation counseling services.
CMS releases new coding guidelines for 3D mammography
When billing for mammography services, please use the following G codes for services Jan. 1 2017 and thereafter: G0202,
G0204, and G0206.
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Additional information from CMS is available here:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-MammographyServices-Coding-Direct-Digital-Imaging.pdf
Comply with clinical information requests
Empire requires that treating physician, clinician or supplier comply with all requests for documentation from the Plan.
Providers are responsible for providing any and all related medical records, answer questions from health plan
representatives or furnish any necessary information when requested. Information must be submitted in a timely manner, be
complete and legible as well as identify the provider and date of service.
The Centers for Medicare & Medicaid Services recently added an additional requirement for health plan peer reviewers to
contact contracted and non-contracted providers to gather medical information needed to make a coverage determination
(https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/HPMS-Guidance-on-Outreach-for-Informationto-Support-Coverage-Decisions-2016Oct18.pdf.) CMS expects plans “to make reasonable efforts to gather all of the
information needed to make substantive and accurate decisions as early in the coverage process as possible.”
Empire peer reviewers look forward to working with you to ensure that our members’ coverage determinations are made in a
timely manner.
New G codes for home health agencies
For dates of service on and after Jan. 1, 2017, a separate payment will be made to home health agencies (HHAs) who are
reimbursed on a CMS PPS methodology and billing for disposable Negative Pressure Wound Therapy (NPWT) devices when
furnished to a patient who receives home health services for which payment is made under the Medicare home health
benefit. To receive separate payment for NPWT, in addition to billing a claim with type of bill 32X, HHAs must bill a claim
with type of bill 34X, HCPCS 97607 or 97608 and the appropriate revenue code 042X, 043X or 0559.
Effective for Jan. 1, 2017 and thereafter, G0163 and G0164 will be retired and replaced with the following four new G-codes:
1. G0493 - Skilled services of a registered nurse (RN) for the observation and assessment of the patient’s condition,
each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate
the patient’s need for possible modification of treatment in the home health or hospice setting).
2. G0494 - Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient’s
condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and
evaluate the patient’s need for possible modification of treatment in the home health or hospice setting).
3. G0495 - Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member,
in the home health or hospice setting, each 15 minutes.
4. G0496 - Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family
member, in the home health or hospice setting, each 15 minutes.
New place of service code 02 for telehealth services
Effective Jan. 1, 2017, Empire is following CMS in implementing new place of service code 02. The new place of service
code 02 is for use by physicians or practitioners furnishing telehealth services from a distant site. When billing telehealth
services, distant site providers must bill with place of service code 02 and continue to bill modifier GT (via interactive audio
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and video telecommunication systems) or GQ (via asynchronous telecommunications system). Telehealth services not billed
with the new place of service code 02 will be denied back to the provider.
See https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.html for the list of Medicare
Telehealth services.
New to Medicare Advantage? Complete OptiNet assessments to avoid line-item denials
All participating Medicare Advantage providers who provide imaging services must complete registration for AIM’s online
registration tool, OptiNet. OptiNet will collect modality-specific data from providers who render X-ray, ultrasound
(abdominal/retroperitoneum, gynecological and obstetrical services only at this time), Magnetic Resonance (MR), Computed
Tomography (CT), nuclear medicine (NUC), positron emission tomography (PET) and echocardiograph imaging services.
Areas of assessment include facility specifications, technologists and physician qualifications, accreditation, equipment and
technical registration.
These data will be used to calculate scores for providers who render imaging services for our individual Medicare Advantage
members.
All participating providers who provide imaging services, including X-rays and ultrasounds as noted above, must
complete the registration. Providers who do not register, who score less than 76 or who do not complete the survey
will receive a line-item denial for the technical component of the outpatient diagnostic imaging service only. This
includes providers who have delegated risk arrangements and who may see Empire members outside of those risk
arrangements.
Participating providers who have already completed the survey but scored less than 76 can use the online
registration at any time to update their information and potentially improve their score. All providers, including those
who score less than 76, will receive individualized information they can use to improve their score.
If you have already completed an OptiNet assessment, please ensure that you keep your registration up to date. Expiring
data could lead to a negative impact in your modality scores.
Facilities billing on a UB-04 claim form will be excluded from line item denials at this time.
The provider registration is available online at www.providerportal.com
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Select Empire MA from the drop down menu
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Only those providers who have completed the provider registration will be able to view their information online
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If you have questions or need help completing the registration, please call AIM Customer Service at 800-714-0040,
Monday-Friday, 8 a.m.-8 pm ET.
Additional information is available at empireblue.com/medicareprovider under Important Medicare Advantage Updates.
64579MUPENMUB 12/14/2016
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Review high-risk medication reports
Empire is required to monitor prescriptions activity for high-risk medications as defined by The Centers for Medicare and
Medicaid Services (CMS) to improve patient safety.
To ensure providers are aware of any high-risk medications prescribed for our Medicare Advantage members, we fax a list of
high-risk medication claims to providers each week.
Empire also distributes a monthly report to prescribers detailing the number of members on high-risk medications and the
number of high-risk medications prescribed year-to-date. We also contact members who have filled prescriptions for high-risk
medications and suggest that they discuss the prescription with their physician and ask if there is a safer alternate drug.
If you receive a high-risk medication fax or report from Empire, please review it and help us support safe medication
choices.
AccordantCare™ to provide support for Individual Medicare Advantage members with HIV
Empire works with AccordantCare™ to provide targeted disease management services for our individual Medicare Advantage
members with a number of rare medical conditions. Effective Feb. 1, 2017, AccordantCare added Human Immunodeficiency
Virus (HIV) management to the rare condition management program.
Members in your care who may benefit from additional outreach and information may receive letters, emails or phone calls
from AccordantCare and Empire. In the course of performing these activities, a nurse may contact you or your facility to
obtain member information and/or AccordantCare may request medical information about Empire members. AccordantCare
and Empire also will let you know of any health changes that may require your attention.
Members must give AccordantCare written consent that it can communicate any medical health changes to you. If the
consent is not given by the member, AccordantCare will not be able to disclose any information to you.
If you feel that an individual Medicare Advantage member would benefit from this program, please have the member contact
AccordantCare via phone or fax at 1-866-247-1150.
Medicare Supplement – please wait 30 days from Medicare remittance date before submitting
another claim
All Blue Cross Blue Shield Association plans, including Empire, are required to process Medicare crossover claims for
services covered under Medigap and Medicare Supplement products through the Centers for Medicare & Medicaid Services
(CMS). This eliminates the need for providers to submit an additional claim directly to Empire.
When a Medicare claim has crossed over to Empire for secondary payment, providers should wait 30 calendar days from the
Medicare remittance date before submitting another claim to Empire. Providers can identify if a claim has been crossed over
for secondary payment by the following Medicare Remittance Advice remarks:
Medicare remittance advice remark codes MA18 or N89 indicate that Medicare crossover has been forwarded to the
secondary carrier:

MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any
questions regarding supplemental benefits to them.

N89 Alert: Payment information for this claim has been forwarded to more than one other payer, but format
limitations permit only one of the secondary payers to be identified in this remittance advice.
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If you use a claims clearing house to file Medicare Supplement claims, please ensure the clearing house waits 30 calendar
days from the Medicare remittance date before submitting another claim to Empire.
Keep up with Medicare news
Please continue to check Important Medicare Advantage Updates at empireblue.com/medicareprovider for the latest
Medicare Advantage information, including:

Risk Adjustment and Documentation Guidance Training Offered

Retrospective medical record review program launches

Home Health Services for Medicare Advantage Individual Members to Require Prior Authorization
65088MUPENMUB 02/13/2017
Medicaid
Behavioral Health Medication Management program
The Empire BlueCross BlueShield HealthPlus Behavioral Health (BH) Medication Management program targets the specific
needs of Empire BlueCross BlueShield HealthPlus members using BH medications. Our goals are to specifically improve the
quality of care provided to our members and promote member adherence to prescribed medication treatments.
Empire BlueCross BlueShield HealthPlus conducts proactive outreach and education programs that focus on:

Reducing polypharmacy

Promoting age appropriate use of BH medications

Providing new start and adherence education
The outreach and education programs also support BH-related HEDIS®* measures such as:

Antidepressant Medication Management (AMM)

Follow-up Care for Children Prescribed ADHD Medication (ADD)

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)

Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)

Use of First-line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)

Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
(SSD)
To learn more about the BH Medication Management program, call Pharmacy Operations at
1-800-719-4871 Monday through Friday between 8:30 a.m. and 4 p.m. ET.
Primary Care Provider Fax Change Form Available
A Primary Care Provider (PCP) Fax Change Form has been posted to our website. The form was created to help providers
save time and resources and is available for use immediately. The PCP Fax Change Form can be found under the Account
Management section of the Provider Support tab of our website, www.empireblue.com/nymedicaiddoc
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Genetic Testing services to require prior authorization
Effective May 1, 2017, Empire BlueCross BlueShield HealthPlus will require prior authorization (PA) for Epidermal Growth
Factor Receptor (EGFR) Testing, Prothrombin G20210A (Factor II) Mutation Testing, Methylenetetrahydrofolate Reductase
Mutation Testing and Cell-Free Fetal DNA Based Prenatal Testing.
All requests must be reviewed for PA dates of service beginning on or after May 1, 2017.
Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, and
including definitions and specific contract provisions/exclusions, take precedence over these prior authorization rules and
must be considered first when determining coverage.
Non-compliance with the new requirements may result in denied claims. PA requirements will be added to the following
codes:

81235, 81291, 81420, 81507 and 0009M
Please use one of the following methods to request PA:

Phone: 1-800-450-8753

Fax: 1-800-964-3627

Visit the web: www.empireblue.com/nymedicaiddoc
If you have questions about this communication or need assistance with any other item, please call Provider Services at
1-800-450-8753.
Additional information on ClaimCheck® upgrade to ClaimsXten™
Empire BlueCross BlueShield HealthPlus previously announced plans to upgrade from ClaimCheck to the ClaimsXten
auditing system in the second quarter of 2017.
This upgrade will continue to ensure claims auditing remains consistent with accepted industry coding standards. However,
claim results may present differently than those processed in the earlier software even though the end result is the same.
The new software uses a set of explanation codes that differ from those currently in use. Along with the new explanation
codes, any updated associated descriptive text will display on the provider Explanation of Payment (EOP) or Clear Claim
Connection explaining the edits applied to the submitted claim, just like today.
You may notice another difference on the EOP when ClaimsXten applies an edit based on the number of units billed.
Currently, claims receiving an audit due to units that exceed the maximum allowed are displayed on two separate lines. The
new software will still show separate lines for claims with less than 100 units, but claims with units billed greater than 100 will
be displayed on a single line showing the reimbursement amount and the number of allowed units.
If you have questions regarding ClaimsXten edits you receive on your EOP, please call Provider Services at 1-800-450-8753.
PAVE Provider Breakfast Forums & Webinars
PAVE is pleased to announce the 2017 provider breakfast forums and webinars presented by the Provider Added Value and
Experience (PAVE) group. PAVE drives collaboration between Empire and the Medicaid provider network with a strong focus
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on education. These sessions are designed to offer information and resources for providing the highest quality patient care.
For the full schedule of forums and webinars and online registration links, visit: http://bit.ly/EmpirePAVE
Federal Employee Program
New benefit for the Federal Employee Program®
The Gender Reassignment Surgery (GRS) Benefit was added January 1, 2017 to provide surgical benefits for the treatment
of gender dysphoria for members age 18 or older. The Blue Cross and Blue Shield Service Benefit Plan brochure, available
on fepblue.org, outlines all criteria and requirements to utilize the GRS benefit.
The GRS benefit requirements include but are not limited to the following list:

A diagnosis of Gender Dysphoria by a qualified health professional.

A prior approval is required for surgeries requested.

A treatment plan with all surgeries listed and the proposed plan of care

Inclusion of two referral letters from qualified mental health professionals
A Provider Toolkit for the Gender Reassignment Surgery (GRS) benefit is available that lists all prior approval requirements
and includes form fields to enter name(s) and contact number(s). A list of covered procedures is included with the Toolkit. To
request this Provider Toolkit, call our Utilization Management toll-free number 1-800-860-2156 to speak to a Utilization
Management representative. To assist with the prior authorization of the services requested, a completed Provider Toolkit
and the required documentation must be provided to the Plan.
For prior approval requests, it’s important to identify the Care Coordinator and/or the referring Provider who would be the
single point of contact for all care for the member’s gender reassignment. Providing this contact name will assist in the prior
approval process. If you do not have the Care Coordinator or referring Provider contact information, please ask the member
to call the Utilization Management department toll-free number 1-800-860-2156 to provide the name of his/her Care
Coordinator to a UM Nurse or intake representative.
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