Category: BCBS Empire NY

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

Posted in #reimbursement, BCBS Empire NY, NY Providers, Updates

Empire BCBS NY: Pharmacy Reimbursement Policy update 1/1/24

Posted on by KR2Medical Billing

According to the announcement by Empire BCBS for the state of NY- the payer added a new INFORMATIONAL modifier to represent the unused drug when the provider uses a single vial of medication/biologic. This policy applies to commercial Plan types.

Reimbursement Policy Number: C-11031. https://www.empireblue.com/docs/public/inline/C-18001_NY.pdf

Although the effective date of the policy is 6/17/23 the policy will only apply to the drugs/biologics that are administered to the member for DOS 1/1/24 and thereafter

JW modifier is not permitted when the actual dose of a covered drug/biologic administered from a single dose vial is less than the billing unit, as indicated in the HCPCS code description.

When administering medication/biologic, the provider needs to be conscious of what amount of medication the patient needs for their treatment. For example, if the provider requires 20 units and the medication/biologic drug comes in a 10 or 50 mil vial, then the provider should use the 2 10 mil vials to administer the needed dosage instead of using the 50 mil vial and appending the JW modifier to the unused portion of the medication/biologics.

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UHC Medicaid: Idaho: diabetic DME coverage change-benefit

Starting for DOS 4/1/26 and thereafter the following codes will be covered through the patient pharmacy benefit and no longer will be covered under patient medical benefit. For DOS 1/1/26 through 3/1/26- providers can still bill either through medical benefit or pharmacy benefit. Find this type of content useful? Follow my blog!

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Anthem BCBS: 32BJ fund new TPA and cards

As the new year starts so do the change of theember ID changes and or group numbers. Is your provider office aware of these changes? Please note that for any 32BJ members there is a new TPA, group#, member ID, and cards. Please note the new ID: Effective Jan 1,2026- new members ID prefix BJVBJ.…

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Are you leaving revenue on the table?

Aetna update! Is your practice compliant? Are you appending proper modifiers to radiology, diagnostic services and surgery services- when billed with the following ICD-10 codes: Z53.01, Z53.09, Z53.1, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9? As per Aetna- if the following modifiers are not billed on the claims for the above services with above named ICD-10 codes-…

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Posted in BCBS Empire NY, NY Providers, Payers and CPT reinbursement, Pharmacy (Various Insurance Payers), Training, Updates

BCBS Empire NY Medicaid: Reimbursement for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Counseling program

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If you are a pediatrician that provides vaccination counseling for patients under 18 years of age and younger then this blog post is for you!

The following is a clarification on the proper coding and billing for or provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.

This reimbursement policy applies to Medicaid members (Empire BCBS).

Note: Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)

The following is the correct CPT code with the ICD-10 code that the providers would use in order to get proper reimbursement.

 CPT® codeFeeNotes
Claims basedCPT 99401DX: Z71.85$12.50A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger.
via Empire BCBS Medicaid Updates

Documentation requirements: In order to get paid for the above mentioned code, the providers need to document the following in either the medical record or a pharmacy record.

  • CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
  • Providers should bill CPT 99402 with ICD-10 code Z71.85.
  • Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
  • Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
  • For more information, visit https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

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Posted in BCBS Empire NY

BCBS: 32BJ Health Fund Plan- Bariatric Surgery and Joint Replacement Surgery

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If you are a surgeon that performs bariatric surgery or joint replacement surgery and see 32BJ Health Fund (BCBS) patients in your office, then this important update is for you! The change will take affect for all surgeries done on DOS 01/01/2022 and thereafter.

32BJ Health Fund has partnered with Hospitals in NY, New Jersey, Connecticut, Massachusetts, Pennsylvania, and Florida to implement a Centers of Excellence (COE) Program for Bariatric and Joint Replacement surgeries.

1.Identifying 32BJ Health Fund patients:

32BJ Health Fund patients are easily identified by the prefix “ETRBJ.”, on their insurance card.

2.Coverage for Bariatric Surgery and Joint Replacement Surgery:

Patients will only be covered if the bariatric surgery and/or joint replacement surgery is performed in one of these COE centers. There will be a $0 copay with a 30 day follow up, after surgery.

32BJ Health Fund patients are NOT COVERED for bariatric and joint replacement surgeries performed by a non-COE provider or at a non-COE hospital.

3.Locating a participating COE provider or COE Hospital:

In order to locate a participating COE provider and a COE Hospital, members need to contact: Plan participants may call 32BJ Member Services at (800) 551-3225.

Providers may call Empire Provider Services at (800) 676-2583.

In addition, 32BJ Health fund patients who live within 50 MILES OF COE Hospital, HAVE to perform their surgery performed by a COE provider at a COE hospital.

(More than 90% of 32BJ members live within 50 miles of a COE hospital.)

More information for Providers:

Any provider looking for more information—particularly anyone currently caring for 32BJ plan participants who may be candidates for bariatric or joint replacement surgery—should call Empire Provider Services at 1-800-676-2583.

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