Category: NY Providers

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

Posted in #reimbursement, #unitedhealthcare, NY Providers, Updates

UHC: Empire Plan updates

Posted on by KR2Medical Billing

If you are a provider that accepts UHC Empire Plan in NY or a patient that has Empire plan then there are several important things that you should take notice of.

  1. Out of network allowed amounts: according to UHC- the reimbursement for OON providers is based on Medicare rates.
  2. Out of network acupuncture services: no matter how many providers that the member visits the maximum # of allowed visits is 20 per calendar year
  3. In network massage therapy services: only 20 visits are covered, per calendar year.
  4. Empire Plan mental health program that is administered by the Carelon Behavioral Health partnered with Hazelden Betty Ford Foundation to provide substance abuse services to the Empire plan members at no cost. Outpatient services are available in California, Florida, Illinois, Minnesota, New York, Oregon and Washington. Prior authorization is required.

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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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