Pharmacy (Various Insurance Payers) – Page 2

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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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MVP NY Medicaid Patients: coverage for Farxiga tablets

Posted on May 16, 2022May 16, 2022 by KR2Medical Billing

If you are a physician prescribing Farxiga for any of your patients that have NY MVP Medicaid Coverage, this blog post is for you!

Farxiga may be considered for coverage when used for one of the applicable FDA-approved indications including:

For the reduction of heart failure hospitalizations in adults with Type 2 diabetes mellitus and
established cardiovascular (CV) disease or multiple CV risk factors
For the treatment of heart failure with reduced ejection fraction (NYHA classes II to IV) to
reduce the risk of cardiovascular death and hospitalization for heart failure
For the treatment of chronic kidney disease to reduce the risk of sustained eGFR decline, endstage kidney disease, cardiovascular death, and hospitalization for heart failure in those at-risk
of disease progression

There are 2 other medications that are on the MVP Formulary that do not require prior authorization (such as Segluromet and Steglatro).

If the patient requires Farxiga then the physician needs to obtain a prior authorization.

Please follow the steps: (ALL requests have to have documentation submitted to support the use of Farxiga)

A. Visit mvphealthcare.com/Providers and Sign In to your Provider online account to use the new electronic prior authorization tool powered by Novologix®.
B. Complete the appropriate MVP prior authorization form, which can be accessed at
mvphealthcare.com/Providers, then select Forms, then under Prior Authorization, select the appropriate form in the Pharmacy section. Then, fax completed request form to MVP at 1-800-376-6373.
C. Submit a request through Surescripts.com or CoverMyMeds.com. ( covermymeds is also available on NAVINET)

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