Posted in #aetna, #Medicare, Updates

Aetna puts Cataract Surgery on National Precertification List 07/01/21

Effective July 1, 2021, Cataract Surgery will require a prior authorization and will be placed on the National Precertification List. (NPL)

Please see the list of related codes below:

In order to request an authorization, providers have several options:

Use AETNA provider portal on Availity® to request precertification electronically. You’ll also give us the necessary clinical information. It’s a simple two-step process:
• Submit* your authorization request on Availity using the
“Authorization (Precertification) Add” transaction.
• Then, complete a short questionnaire, exclusively on
Availity, to provide us with additional clinical information. You can register for Availity on their website. Aetna also offers training on how to use Availity to submit precertification requests
for cataract surgeries electronically. Visit AetnaWebinars.com for a schedule and to register for the “Authorizations on Availity” webinar.

Phone requests are only allowed in certain states: Georgia and Florida for MEDICARE PATIENTS.

Georgia Medicare only (MEHMO and MEPPO), contact iCare
at 1-844-210-7444
• Florida Medicare only (MEHMO and MEPOS), contact iCare at
1-855-373-7627

#Aetna, #cataractssurgery, #cataracts, #66988, #aetnamedicare, #medicare.

Posted in BCBS Empire NY, Updates

Empire BCBS (NY) and SOMOS IPA Utilization Management

Reminder that effective 10/01/2020- SOMOS IPA will assume the administrative functions for several Empire HealthPlus Plans:

Medicaid Managed Care (MMC)

Health and Recovery Plan (HARP)

Child Health Plus (CHPlus)

Essential Plan programs

SAMPLE EMPIRE SOMOS IPA CARDS:

FRONT OF THE CARD
BACK OF THE CARD

Contacting SOMOS for patient Eligibility, benefits and authorizations: OON and IN providers

Credentialing process:
• SOMOS IPA providers: SOMOS will handle all credentialing for its participating providers. This
includes the submission of any demographic changes or terminations.
• Non-SOMOS IPA providers: Providers who are not contracted with the IPA must continue to follow the Empire processes.

For more information please click here.

Posted in BCBS Empire NY, Updates

Empire BCBS (NY) Voluntary Cancer Care Quality Program (changes 07/01/2021)

According to Empire BCBS NY: in order to align the program intention to support member care coordination and to ensure compliance with regulatory requirements surrounding the program, Empire BCBS is amending the approach for enhanced reimbursement that accompanies selection of ‘on-pathway’ chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program. 

Starting 07/01/2021, authorization process for on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy, will be adjusted to reflect specific regiments and enhanced reimbursements, for the medical oncologists.

Which regiments are affected?

Only select oral and hormonal agents for which a monthly in-office visit may not be required.

For the complete list please click here.

Which Authorizations will be affected?

This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates. 

Which HCPCS codes will be affected?

Billable S-codes for treatment planning and care coordination management for cancer.

How will be the payment affected for the billable S-codes?

The optional enhanced reimbursement award will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353)

AIM/Empire will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support. 

If you have any questions, please Contact your Empire network representative or your oncology provider engagement liaison for more information.

Click here for the full updated Cancer Treatment Planning and Care Coordination policy (Commercial Plans)