Category: NY Providers

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

Posted in EmblemHealth NY, NY Providers, Payer Updates, Payers and CPT reinbursement

EmblemHealth Medicaid Plan Update: prenatal/postpartum

Posted on by KR2Medical Billing

Effective for DOS 4/15/25 and thereafter EmblemHealth (Medicaid LOB) will require extra CPT II codes on the global maternity claims.

The following codes need to be present on the claims:

  1. 0500F (Initial Prenatal Visit)
  2. 0502F (Subsequent Prenatal Visit) or
  3. 0503F (Postpartum visit) for each corresponding visit provided to the patient within the obstetric global period being billed

These codes are NOT separately reimbursed- they are only for reporting purposes.

The reimbursement is included in the global code 59400.

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Posted in #reimbursement, BCBS Empire NY, NY Providers, Training

Anthem BCBS (NY providers): PA/NP reimbursement

Posted on by KR2Medical Billing

According to Anthem BCBS (NY) starting for any DOS 11/1/24- the PA/NP will be updated to align with CMS guidelines.

Please note the following services will be eligible to be performed by the PAs/NPs and reimbursement reduction will apply:

– Preventative care services

-Radiology services

Services that are not going to be reimbursed separately:

-Drugs

-Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)

-Laboratory Services and Laboratory Screening Services

Billing: PA/NP has to bill with their own TIN and NPI number.

For the full policy please click here:https://www.anthembluecross.com/provider/policies/reimbursement/

CMS payment for NP/PA services:

-NP services: 85% of Physician Fee for outside of hospital setting or SNF, or 80% of lesser billed charge

-NP services : incident to services done by auxiliary personnel outside hospital or SNF setting – 85% of Physician Fee Schedule

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/advanced-practice-registered-nurses-aprns

-PA services: 85% of PFS- physician fee schedule.

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/physician-assistants-pas

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Posted in #reimbursement, EmblemHealth NY, NY Providers, Payer Updates, Payers and CPT reinbursement

Emblem Health Doula coverage/reimbursment-1/1/25

Posted on by KR2Medical Billing

Are you a NYS registered doula and thinking about seeing Emblem Health members? Then this post is for you! #reimbursement

According to Emblem Health- the following plans will be covered for the dollar services:  Medicaid, HARP and Essential Plans.

The services are covered in hospitals, clinic and community settings for members that are pregnant, are giving birth, and postpartum.

The following table is reimbursement information:

Via Emblem Health

Coding information: as per eMedNY – doula fee schedule

Need more information about NYS Doula services please click here:https://www.emedny.org/ProviderManuals/Doula/

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