Posted in Insurance, Training, Updates

EmblemHealth (NY)-Care Management Program for Kidney Patients, 05/01/21

Starting 05/01/21- EmblemHealth (NY) will offer the EmblemHealth Chronic Kidney Disease (CKD)/End Stage Renal Disease (ESRD) program.

What will this mean for your patients?

  1. EmblemHealth team of care managers, social workers, and pharmacists may be in touch with the physician’s office as they coordinate patient care.
  2. EmblemHealth is going to manage members affected by kidney disease

What will the EmblemHealth CKD/ESRD program do?

  1. The CKD/ESRD program will provide eligible members with holistic, seamless and, clinically robust wrap around support throughout all stages of their health care journey

What is the purpose of EmblemHealth CKD/ESRD Care Management Program?

  1. EmblemHealth’s CKD/ESRD program aims to slow the progression of illness and reduce unnecessary utilization. The program seeks to improve condition management and navigation of the healthcare system through a structured approach to person-centered assessment, care planning, and delivery of interventions.

Who will select the patents?

  1. EmblemHealth will identify members with complex needs and provide them with individualized care management interventions.

How to get in touch with EmblemHealth CKD/ESRD Care Management Program Staff?

  1. For more information or to make a referral, call us as at 800-447-0768, Monday through Friday, 9 a.m. to 5 p.m.
Posted in Insurance, Payer Updates, Prior Authorization Insurance Carrier Updates, Training, Updates

BCBS of Tennessee (Commercial Plan) Update: MSK Prior Auth List expanded

Changes to Musculoskeletal (MSK) Program Prior Authorization for Commercial Plans: new Codes are added to the MSK Prior Authorization List: effective date 05/01/2021

This change only applies to to Blue Network P SM and Blue Network S SM unless stated otherwise.

The codes will require an authorization for the members that have the MSK Program Benefit.

The following codes will be added:

Posted in Insurance, Training, Updates

MVP Plans (NY) Cardiovascular and Ophthalmology TC Reimbursement Policy 2021

Full Name of this policy is: Multiple Procedure Reduction on the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures Payment Policy

Effective Date is February 03/2021

This policy will follow the reimbursement standards set forth by the CMS, under the MVP Multiple Procedure Payment Reduction (MPPR) policy. The MPPR policy regarding diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPR policy applies independently to cardiovascular and ophthalmology services. The MPPR policy applies to TC-only services, and to the TC of global services.

For cardiovascular services: 100% reimbursement is made for the TC service with the highest payment. Reimbursement is made at 75% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day.

For ophthalmology services: 100% reimbursement is made for the TC service with the highest payment. Reimbursement is made at 80% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same group NPI) to the same patient on the same day. The MPPR policy does not apply to the professional component.

The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures are in Attachments 1 and 2 of CR7848 respectively. CR7848 is available at http://www.cms.gov/Regulations[1]and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf

Source: MVP provider fax announcements.