Category: NY Providers

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Posted in HealthFirst, NY Providers, Payer Updates, Training, Updates

HealthFirst: new vision insurance payer

Posted on by KR2Medical Billing

HealthFirst members will no longer have coverage through Davis Vision and Superior Vision effective 1/1/24.

Optometry and Ophthalmology specialists that perform routine vision services and medical optometry services for HealthFirst members will now need to get contracted with the new vision insurance payer: EyeMed.

Starting 1/1/24, EyeMed will handle network management, prior authorization process, member and provider services, as well as claim payments for all routine services and medical optometry services (HealthFirst members)

Providers please contact EyeMed at EyeMedInFocus.com/Join to start the xontracting process.

Below please see the list (not all inclusive) of services that require prior authorization.

Not all inclusive

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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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Posted in NY Providers, Payer Updates, Updates

EmblemHealth updated timely filling date (claims) for self funded plans!

Posted on by KR2Medical Billing

According to EmblemHealth-for self funded plans: Local 389 Health and Welfare fund- for the DOS 9/1/23 and thereafter have a new timely filling date for submitting claims. The new date is 90 days after the services were rendered.

This new time frame applies to In network and Out of Network providers.

Types of claims: professional, facility and other provider types

Please note that this change DOES NOT APPLY to the other ASOs (Administrative Service Organizations).

The following is still in affect:

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In a meantime check out my other blog posts:

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HealthFirst Telehealth mental health modifier update

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AETNA Commercial Plans: compression supplies non covered codes.

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