Category: #reimbursement

Posted in #reimbursement, BCBS Empire NY, NY Providers, Payer Updates, Prior Authorization Insurance Carrier Updates

Anthem BCBS NY: New PET tracer UM policy

Posted on by KR2Medical Billing

The following information will apply to any DOS on 12/1/25 and thereafter.

Starting 12/1/25 the PET tracer will require an auth in addition to PET services.

Please submit both PET and radiotracer codes- for prior authorization. The UM criteria for PET will not be affected. However both codes will be either approved or denied. Please note that the radiotracer must coorespond to the requested PET code.

The following codes will be affected:

Image via Anthem BCBS
Image via Anthem BCBS
Image via Anthem BCBS

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Posted in #aetna, #reimbursement, NY Providers, Payer Updates, Training

PrEP proper billing and coding

Posted on by KR2Medical Billing

Proper Medical coding and billing is important to the financial health of your practice!

Medication codes:

Image via Google

Administration code

Please avoid using the regular 96372 administration code. Instead use the following administration code: G0012

This code is used when the provider physically administers the PrEP medication.

Supply Code

For the oral PrEP pharmacies should bill: Q0251

Image via Google

ICD-10 codes:

F19.10, F19.20, Z11.3, Z11.4, Z20.2, Z20.6, Z29.81, Z72.51- Z72.53, Z72.89, Z79.899

These services are classified as preventative medicine.

Based on which insurance payers your office accepts, there can be some variations of coverage to the additional services that may be related to PrEP. Please make sure you check with the insurance payers before performing any services for additional coverage information.

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

BcBS HighMark NY: coverage for COVID-19 vaccine

Posted on 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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