Category: NY Providers

Find Medical Billing and Coding guidance for any Providers that operate in NY State

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

BCBS (NY): HIV medication combinations may require Prior Auth, 05/01/2021

Posted on by KR2Medical Billing

Effective 05/01/21 and for the DOS thereafter, BCBS (Empire) NY, will implement a new prior authorization for HIV medications/drugs. This would help to ensure that the patients are not receiving therapeutic duplications when taking certain combinations.

In order for the Member to continue to receive the treatment that involves drug combinations, the provider must submit an authorization for EACH Drug and provide a MEDICAL NECESSITY rationale as to why that drug combination is clinically needed.

Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.

Examples of HIV drug combinations that would trigger duplicated drug combinations:

Providers and members expected to be impacted by this policy will receive advanced notice by mail.

Source: BCBS (NY) Providers Communications: March 2021

Posted in MVP (NY/VT) Insurance Payer, NY Providers, Training, Updates

MVP NY – Home Health Approval Process-New 2021

Posted on by KR2Medical Billing

This new process is an auto-approval, that would streamline the first time initial HH request.

This policy change applies to all MVP Medicare Advantage Members requiring HH admissions.

Provider will have to send in their request through naviHealth.

The providers will receive 10 pre-approved visits, which would include the Start of Care (SOC) visit.

Starting 01/01/2021- naviHealth will utilize Change Healthcare’s InterQual home health criteria for continued stay requests, additional services, and recertification’s.

Education:
• naviHealth will provide educational webinars (Details to come)
What will the webinars include?
• An overview of the new HH auto-approval process
• A detailed look at the revised naviHealth HH authorization request form
– There will be an opportunity for questions & answers
Who should attend?
• HH agency billing/Insurance areas
• HH agency intake department manager

Please contact the naviHealth Senior Clinical Manager, Monica Bean at mbean@navihealth.com with any questions.

Source: MVP fax Provider Communications.

Posted in BCBS Empire NY, NY Providers, Training, Updates

Empire BCBS (NY) Changes to AIM Small Joint Surgery Guideline for 2021

Posted on by KR2Medical Billing

Reminder: as of 11/01/2020 IM Specialty Health® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Empire BlueCross BlueShield (“Empire”) fully insured members and some ASO groups.   

Effective 03/14/2021, the following changes will be made to the Small Joint Surgery Guidelines:

  • Clarified requirements for imaging reports.
  • Removed radiographic requirement for confirmation of lesser toe deformities.
  • Ankle arthrodesis and total ankle arthroplasty added as new indications for revision of failed previous reconstructions.
  • Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis.
  • Clarified contraindications only apply to total ankle arthroplasty.

How to request an authorization:

  • Access AIM ProviderPortalSM directly at providerportal.com. 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 Portal at availity.com
  • Call the AIM toll-free number at 1-877-430-2288, Monday through Friday 8:30 am – 7 pm ET.

For further questions, please contact the provider number on the back of the member ID card.