Category: #Medicareadvantage

Posted in #Medicare, #Medicareadvantage, #reimbursement, EmblemHealth NY, NY Providers, Payer Updates, Pharmacy (Various Insurance Payers), Training

Emblem Health new Specialty Meds/Pharmacy Policy

Posted on by KR2Medical Billing

Effective 7/14/25 there is a new specialty pharmacy policy will apply to all of Emblem Health lines of busines: commercial, Medicare, medicaid.

Image via emblemhealth

This policy applies to all outpatient providers in the following place of service: outpatient hospital, physician office,home of the member and ambulatory infusion.

Takeaways:

1. According to this policy the providers need to contact the respective specialty pharmacy to request prior auth and are only allowed to bill for specialty medications administration NOT the medication itself.

2. The Specialty Pharmacy will be allowed to bill Emblem health under the member’s medical benefit and receive reimbursement.

Image via EmblemHealth

3. For any Medicaid EmblemHealth plan- the medicatin codes must be on Medicaid Fee Schedule. If the code is not listed it will not be reimbursed.

Exclusion: this policy does not apply to home infusion providers.

For a full list of specialty medications please visit Emblem Health for more information and a PDF version of the policy

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Posted in #Medicareadvantage, #reimbursement, Cinga Insurance, Payer Updates, Payers and CPT reinbursement

Aetna: Cologuard reimbursement

Posted on by KR2Medical Billing

As per Aetna for their Commercial and Medicare Plans: Cologuard test will be denied when it is performed within a year that the patient had a Colonoscopy.

Colonoscopy codes: 45378–45398 or G0121

This will be effective for any DOS on Jan 1,2025 and thereafter.

What is Cologuard?

According to the Cologuard website: the non-invasive at home colon cancer screening test that is available for patients 45 and older who have an average risk of colon cancer.

What is an average risk?

Patients that do not have a history of colon cancer in their family or personal history, as well as IBD.

Please note that there is no specific insurance information that is available on the Cologuard website. Cologuard might not be covered at all with your insurance. Please double check if it going to be covered before doing it.

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Posted in #aetna, #Medicareadvantage, #reimbursement, Training, Updates

Aetna: Reimbursement for evaluations with G2082 and G2083 codes…

Posted on by KR2Medical Billing

According to Aetna, effective for DOS 3/1/24 and thereafter, evaluation codes 99212-99215, 99415–99417 will no longer be reimbursed separately when billed on the same DOS for the same member by the same provider.

This change will apply to Commercial and Medicare Advantage Plans.

Modifier 25 will not be able to override this claim edit and the payment for the E/M codes will be included in either code G2082 or G2083

G2082-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision up to 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

G2083-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision greater than 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

CTP codes 99415, 99416 are used to report the total amount of face-to-face time spent with the patient and/or family/caregiver by clinical staff in the office or
other outpatient setting, on a given date of service even if the time is not continuous. The
physician or qualified health care professional is present to provide direct supervision of the
clinical staff. Codes 99415, 99416 should not be used for prolonged services of less than 30
minutes total duration on a given date.

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