Pharmacy (Various Insurance Payers)

#reimbursement, BCBS (Various States), BCBS Empire NY, NY Providers, Pharmacy (Various Insurance Payers)

BcBS HighMark NY: coverage for COVID-19 vaccine

Posted on October 12, 2025 by KR2Medical Billing

According to Highmark BCBS- the COVID-19 vaccine will be covered with out any pocket costs through 2025-2026.

This currently only applies to Managed Medicaid, Child Health Plus, Essential and HARP plan types.

The vaccine will still be part of standard preventive care benefits, COVID‑19 vaccines are covered for all members older than 6 months of age.

Members are encouraged to contact their primary care or pharmacy for vaccine availability.

Highmark will partner with Wellpoint companies to administer this benefit.

As per Highmark-Wellpoint Insurance Services, an independent company, administers utilization management services for Highmark Blue Cross Blue Shield’s managed Medicaid.
Wellpoint Partnership Plan, LLC provides management services for Highmark Blue Cross Blue Shield’s managed Medicaid.

Certain sef-insured plans have special vaccine coverage and should check their benefits coverage for more info.

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#Medicare, #Medicareadvantage, #reimbursement, EmblemHealth NY, NY Providers, Payer Updates, Pharmacy (Various Insurance Payers), Training

Emblem Health new Specialty Meds/Pharmacy Policy

Posted on July 16, 2025 by KR2Medical Billing

Effective 7/14/25 there is a new specialty pharmacy policy will apply to all of Emblem Health lines of busines: commercial, Medicare, medicaid.

This policy applies to all outpatient providers in the following place of service: outpatient hospital, physician office,home of the member and ambulatory infusion.

Takeaways:

1. According to this policy the providers need to contact the respective specialty pharmacy to request prior auth and are only allowed to bill for specialty medications administration NOT the medication itself.

2. The Specialty Pharmacy will be allowed to bill Emblem health under the member’s medical benefit and receive reimbursement.

3. For any Medicaid EmblemHealth plan- the medicatin codes must be on Medicaid Fee Schedule. If the code is not listed it will not be reimbursed.

Exclusion: this policy does not apply to home infusion providers.

For a full list of specialty medications please visit Emblem Health for more information and a PDF version of the policy

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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

Posted on July 12, 2022July 12, 2022 by KR2Medical Billing

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^® code	Fee	Notes
Claims based	CPT 99401DX: Z71.85	$12.50	A 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

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