Category: BCBS Empire NY

Find medical coding and medical billing guidance for BCBS Empire NY Plans

Posted in #reimbursement, BCBS Empire NY, NY Providers, Payer Updates, Prior Authorization Insurance Carrier Updates

Anthem BCBS NY: New PET tracer UM policy

Posted on by KR2Medical Billing

The following information will apply to any DOS on 12/1/25 and thereafter.

Starting 12/1/25 the PET tracer will require an auth in addition to PET services.

Please submit both PET and radiotracer codes- for prior authorization. The UM criteria for PET will not be affected. However both codes will be either approved or denied. Please note that the radiotracer must coorespond to the requested PET code.

The following codes will be affected:

Image via Anthem BCBS
Image via Anthem BCBS
Image via Anthem BCBS

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Posted in #reimbursement, BCBS (Various States), BCBS Empire NY, NY Providers, Pharmacy (Various Insurance Payers)

BcBS HighMark NY: coverage for COVID-19 vaccine

Posted on by KR2Medical Billing

According to Highmark BCBS- the COVID-19 vaccine will be covered with out any pocket costs through 2025-2026.

This currently only applies to Managed Medicaid, Child Health Plus, Essential and HARP plan types.

The vaccine will still be part of standard preventive care benefits, COVID‑19 vaccines are covered for all members older than 6 months of age.

Members are encouraged to contact their primary care or pharmacy for vaccine availability.

Highmark will partner with Wellpoint companies to administer this benefit.

As per Highmark-Wellpoint Insurance Services, an independent company, administers utilization management services for Highmark Blue Cross Blue Shield’s managed Medicaid.
Wellpoint Partnership Plan, LLC provides management services for Highmark Blue Cross Blue Shield’s managed Medicaid.

Certain sef-insured plans have special vaccine coverage and should check their benefits coverage for more info.

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Posted in #reimbursement, BCBS Empire NY, NY Providers, Payer Updates, Prior Authorization Insurance Carrier Updates

Anthem BC/BS NY:MLTC Program updates 2025

Posted on by KR2Medical Billing

Are you a provider that provides services for MLTC members that have the MLTC Plan type through Anthem BCBS- then this blog post is for you!

The following changes take affect for any DOS after 3/1/25:

-MLTC member ID numbers

-Electronic funds transfer (EFT): EnrollSafe replaced Payspan as the EFT website.

-Availity Essentials replaced Payspan for provider remittances (ERA).

Authorizations for personal care services, social daycare, and meals will be issued in weekly units and will no longer contain a fixed daily schedule, allowing for greater flexibility in service provision and billing.


Claims-related updates:

-Access claim status information in Availity Essentials.

–Paper claims submission address


-Aligned claim timely filing guidelines.

-Value code and rate code are required for nursing home claims.

-Bill types and revenue codes were aligned for specific service.

-Check run days were changed to Wednesdays and Saturday

What is not affected:

-Authorization information is available on the legacy MLTC Provider Portal.

-Electronic claim submission — Payer ID 45302 for MLTC claims

-EDI claims submissions using Availity Essentials

-Claim dispute process

-Clinical appeal process

-The Care Management, Provider Services, and Provider Relations teams

For more information regarding these changes please visit: Anthem Provider Manual- MLTC

https://providers.anthem.com/new-york-provider/resources/manuals-policies-guidelines

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