Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 1 of 27 Page 3 4 4 5 5 7 7 8 8 9 9 12 13 13 13 14 14 15 18 18 19 19 19 21 21 21 22 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® April 2017 22 22 23 24 24 24 25 25 25 26 26 26 27 2 of 27 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 April 2017 3 of 27 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 April 2017 4 of 27 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.” April 2017 5 of 27 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. April 2017 6 of 27 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 April 2017 7 of 27 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. April 2017 8 of 27 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 April 2017 9 of 27 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 10 of 27 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, 11 of 27 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. April 2017 12 of 27 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). April 2017 13 of 27 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: 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. April 2017 14 of 27 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.) DRUG.00104 - Nusinersen (SPINRAZA™) Revised Medical Policies Effective 02-16-2017 (The following policies were revised to expand medical necessity indications or criteria.) DRUG.00068 - Vedolizumab (Entyvio®) 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.) DRUG.00006 - Botulinum Toxin DRUG.00017 - Hyaluronan Injections in Joints Other than the Knee DRUG.00104 - Nusinersen (SPINRAZA™) 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.) 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.) 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.) 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.) 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.) ADMIN.00001 - Medical Policy Formation ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin BEH.00001 - Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification BEH.00004 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome DME.00012 - Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation April 2017 15 of 27 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 April 2017 16 of 27 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.) LAB.00034 - Serological Antibody Testing for Helicobacter Pylori 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.) April 2017 17 of 27 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.) CG-DRUG-28 - Alglucosidase alfa (Lumizyme®) CG-SURG-27 - Sex Reassignment Surgery 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.) 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.) CG-ANC-04 - Ambulance Services: Air and Water CG-DME-10 - Durable Medical Equipment CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use CG-DRUG-16 - White Blood Cell Growth Factors CG-DRUG-43 - Natalizumab (Tysabri®) CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient) CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift CG-SURG-24 - Functional Endoscopic Sinus Surgery (FESS) 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.) CG-BEH-04 - Substance-Related and Addictive Disorder Treatment CG-BEH-05 - Eating and Feeding Disorder Treatment CG-MED-19 - Custodial Care CG-REHAB-04 - Physical Therapy CG-REHAB-05 - Occupational Therapy 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. April 2017 18 of 27 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. DRUG.00104 - Nusinersen (SPINRAZA™) GENE.00007 – Cardiac Ion Channel Genetic Testing 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 April 2017 19 of 27 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: Cancer Treatment Planning and Care Coordination Surgical Pathology & Related Prostate Needle Biopsy Screening Services with Related Evaluation & Management Services April 2017 20 of 27 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: 1. 2. 3. 4. 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 Effective Jan. 1, 2017, 76706 will replace G0389 for Abdominal Aortic Aneurysms (AAA) G0389 is used for services furnished prior to 01/01/2017. New flu vaccines –Medicare preventive benefit – Part B immunizations 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. 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. April 2017 21 of 27 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 April 2017 22 of 27 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 Select Empire MA from the drop down menu Only those providers who have completed the provider registration will be able to view their information online 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 April 2017 23 of 27 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. April 2017 24 of 27 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 April 2017 25 of 27 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 April 2017 26 of 27 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. April 2017 27 of 27