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

BCBS Empire NY Medicaid: Reimbursement for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Counseling program

If you are a pediatrician that provides vaccination counseling for patients under 18 years of age and younger then this blog post is for you!

The following is a clarification on the proper coding and billing for or provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.


This reimbursement policy applies to Medicaid members (Empire BCBS).

Note: Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)


The following is the correct CPT code with the ICD-10 code that the providers would use in order to get proper reimbursement.

 CPT® codeFeeNotes
Claims basedCPT 99401DX: Z71.85$12.50A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger.
via Empire BCBS Medicaid Updates

Documentation requirements: In order to get paid for the above mentioned code, the providers need to document the following in either the medical record or a pharmacy record.

  • CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
  • Providers should bill CPT 99402 with ICD-10 code Z71.85.
  • Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
  • Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
  • For more information, visit https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

Find this type of information useful? Follow my blog for more proper medical billing and coding guidelines/updates, reimbursement policy changes and much more!


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Posted in Insurance, Payers and CPT reinbursement, Training, Updates

The Empire Plan (NYSHIP)- Prospective Procedure Review and Advance Imaging Procedure Programs Information-getting paid!

The purpose of this post is to go over the needed information on when Prior Procedure Notification is required for The Empire Plan (NYSHIP) members.

According to The Empire Plan Prior Notification is required when The Empire Plan is the primary insurance NOT when it is secondary or tertiary.

The following list of Advance Outpatient Imaging Procedures require a Prior Notification:

1. CT- Computerized Tomography

2. MRI- Magnetic Resonance Imaging

3.MRA- Magnetic Resonance Angiography

4. Nuclear Medicine

5. Nuclear Cardiology

6. PET-Positron Emission Tomography

Q: Are there any exclusions to this?

A: Yes. If the services are performed in Inpatient setting*, Emergency Room, observational unit, or urgent care center they do not require a Prior Notification.

*Note: Inpatient services do not require PPR notification. However, hospital admission might. BCBS is responsible for mandatory pre-admission certification portion of (BMP) Benefits Management Program. This requires a call prior to any elective (scheduled) hospital admission that includes an overnight stay. If the patient is admitted into the hospital please call BCBS with 48 hours.

Q: Does outpatient surgery require a notification call?

A: No

Options for ordering a notification number:

1. Online- UHCprovider.com/Radiology- where providers can select to go to Prior Authorization and Notification APP.

2. Phone: Radiology Notification Line: 866-889-8054, M-F 7am to 7pm EST or

3. Phone: Empire Plan- 877-NYSHIP (877-769-7477) M-F 8:30am- 4:30pm

Q: What information will I need to request a Notification #?

A:  Information about Ordering provider and Rendering provider:

 1. Ordering provider: name, TIN./NPI, Address, Phone#, Fax# and Email

 2. Rendering Provider: name, TIN/NPI (if different), address, Phone#

In addition you need to include Clinical Information:

1. Working Diagnosis with appropriate ICD code(s)

2. Enrollee’s clinical information that should include symptoms, prior treatments, dosage and duration of any medications, plus dates of other therapies.

3. Examination(s) or type of services that are being requested with appropriate CPT code(s)

4. Any other information that ordering provider believes would be useful in evaluating the request.

Remember: in order to ensure that the proper payment is dispersed, the number should be obtained and communicated by the ordering physician/provider to the rendering physician/provider that is scheduled to perform the advanced outpatient imaging procedure(s).

Q: If the procedure was done outside the standard business hours and on urgent clinical basis, is there a retrospective review?

A: Yes. If the services were done outside of UHC normal business hours, the provider needs to contact the Radiology Notification Phone line within the 2 business days of the service(s). Also documentation must have an explanation why the procedure was required on an urgent basis and was done outside of UHC normal business hours.

Posted in Insurance, Payers and CPT reinbursement, Training

UnitedHealthCare COVID-19 Physical , Occupational and Speech Therapies Telehealth Coverage- update 04/20/2020

As of 04/20/2020 UHC announce that it will cover PT, OT and ST services for its members. enrolled in Medicare Advantage, Medicaid, Individual, and Fully Insured Group Market Plans.

This applies to services performed between 03/18/2020 and 06/18/2020

Q.Covered Services?

A. The services have to rendered using interactive live audio-visual technology. During the live video conferencing both parties must be present- patient and the provider.

Q. What is NOT covered?

A. E-mailing “stored” exercise videos to the patient and using a phone to review or discuss them with the patient.  

The providers have to be certified in the given state, where they are providing the service.

Cost sharing will be waived for the services performed by IN-Network providers only. There is an Opt-in option for self funded employers.

Billing & Coding:  Applies to all lines of business.

The complete list of acceptable/reimbursable CPT codes could be found by clicking HERE.

Services that are billed on HCFA 1500 form with modifier 95 with a Place of Services where the services would be furnished in person.

Services that are billed on UB04 should be billed with revenue code 780.

Utilization Management:

There is no change to the utilization management requirements for PT, OT, ST.

Please remember that the claims will be processed based on UHC member’s benefits plan.