Posted in Insurance, Training, Updates

MVP Plans (NY) High Tech Radiology Policy Changes -2021

As of January 1, 2021 the following MVP Plans will no longer require prior authorization for High Tech Radiology Services:

MVP Medicare Advantage Plans

MVP Medicaid Managed Care

MVP Harmonious Health Plan (HARP)

MVP Child Health Plus (CHP)

These services include: MRI/MRA, PET Scan, Nuclear Cardiology, CT/CTA, and 3D Rendering Imaging Services

This applies only to the services rendered by IN Network Providers. For any of the above mentioned plans that do have Out of Network benefits and would like to go to an out of network provider: the Prior Authorization is Required!

To request an authorization: please complete a Prior Approval Request Form (PARF) and fax it to MVP at 1-800-280- 7346.

ALL other MVP plans still require a prior authorization for HIGH Radiology Services. To request an Auth please contact eviCore Healthcare by submitting requests at or by calling 1-800-568-0458.


Posted in Insurance, Payer Updates, Training, Updates

BCBS NY Medicaid: Ocrevus/Vyepti Medical Step Therapy Notice

Starting for DOS on 04/01/2021 and thereafter, the following medications will be added to BCBS NY Medicaid Step Therapy.

Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review.

To see the full clinical criteria/medical policy for Ocrevus, please click here.

To see the full clinical criteria/medical policy for Eptinezumab, please click here.

Posted in Insurance, Payer Updates, Training, Updates

Anthem BCBS (NY) Site of Care review for long-acting colony-stimulating factors, 06/01/2021

This policy is for site of care medical necessity review and it only applies to administration performed in an outpatient hospital setting.

This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.

The medical necessity Review will be performed by AIM Specialty Health® (AIM).

AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Empire’s Medical Policy and Clinical UM Guideline page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.

The following codes apply to this policy:

To Submit a request for review:

Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:

  • Access AIM ProviderPortalSM directly at 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
  • Call the AIM Contact Center toll-free number: 1- 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

This review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at

**Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “site of care.”**