Category: Updates

Posted in EmblemHealth NY, Training, Updates

EmblemHealth Commercial Plan: Infusion POS Policy update

Posted on by KR2Medical Billing

This policy update applies to Commercial and Exchange EmblemHealth Plans and ConnectiCare Plans.

This policy applies to ongoing Infusion maintenance treatment for members that are 21 years and older.

Starting for DOS August 1, 2022 and thereafter, EmblemHealth will start to review ongoing infusion treatments for Site of Services (Place of service).

Preferred POS locations:

o Home (Code 12):
▪ Location, other than a hospital or other facility, where the patient
receives care in a private residence.
o Office (Code 11):
▪ Includes Ambulatory Infusion Suite (AIS)
▪ Location, other than a hospital, skilled nursing facility (SNF), military
treatment facility, community health center, State or local public
health clinic, or intermediate care facility (ICF), where the health
professional routinely provides health examinations, diagnosis, and
treatment of illness or injury on an ambulatory basis.

Non-preferred POS locations would be:

o Off Campus-Outpatient Hospital (Code 19):
▪ A portion of an off-campus hospital provider-based department
which provides diagnostic, therapeutic (both surgical and
nonsurgical), and rehabilitation services to sick or injured persons
who do not require hospitalization or institutionalization.
o On Campus-Outpatient Hospital (Code 22):
▪ A portion of a hospital’s main campus which provides diagnostic,
therapeutic (both surgical and nonsurgical), and rehabilitation
services to sick or injured persons who do not require
hospitalization or institutionalization.

Exceptions apply and will be reviewed after the 6 month interval of treatment has been completed.

Also exceptions that are for initial doses and members with justifiable needs to continue care in a hospital outpatient setting will be allowed.

Prior authorization duration- current authorizations from Express Scripts’ company Care Continuum will be valid through the date noted in their approval letter. 

However, after the current prior auth expires the providers should coordinate the administration of the medication in a preferred POS location.

Partial List of Medications that are covered in this policy and their exceptions.

For complete list of Medications and a whole Policy please click here.

Routine maintenance will be covered in the following outpatient settings:

  • Home (POS 12)
  • Office (POS 11)
  • Ambulatory infusion suites (POS 24, POS 49, or POS 12 with Modifier SS)

Find this type of content useful? Follow my blog for more medical billing and coding guideline changes, prior authorization/medical policy updates and much more!

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Posted in #Medicareadvantage, BCBS (Various States), Training, Updates

BCBS of MN: Reimbursement update (modifiers 52, CO, CQ)

Posted on by KR2Medical Billing

Please note which type of providers will be affected by each reimbursement policy for specific modifiers and the effective date it begins.

The following reimbursement updates take effect as of July 1, 2022:

  1. Modifier 52- for services performed on 07/01/2022 and thereafter, Blue Cross will be begin reimbursing procedure codes billed with a -52 modifier at the lesser of 50% of the physician fee schedule allowance or charge submitted for the following lines of business: • Commercial• Federal Employee Program (FEP)
  2. The Reimbursement Policy, General Coding – 003 Coding Edits will be updated to reflect this change.

PT/OT/ST services reimbursement with modifiers CO, CQ for DOS 07/01/2022 and thereafter:

  1. Commercial plans-

Blue Cross will be implementing a 15% reduction in the allowed amount for services
modified with CO or CQ modifier for professional providers.

The following reimbursement Policy took affect for DOS 01/01/2022 and thereafter

1. Medicare Advantage Plans-

Blue Cross implemented a 15% reduction in the allowed amount for services modified with CO or CQ modifier for professional and facility providers to comply with requirements of the Centers for Medicare & Medicaid Services (CMS).

Find this type of content useful, then follow my blog for more medical billing and coding guideline updates, reimbursement policy changes, and more!

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Posted in #aetna, Training, Updates

Aetna Better Health of Florida to pay for certain Z codes

Posted on by KR2Medical Billing

Do you or your office reports social determinants and accept Aetna Better Health members? Great news! Now according to an update sent to the physicians, the insurance plan will reimburse for certain Z codes that correspond to certain social determinants of health.

Some of these Social Determinants of Health include (not all included):

• Assistance reapplying for Medicaid benefits
• Transportation: ModivCare
• Cleaning: Pest control, carpet cleaning, house cleaning
• Housing Specialist: assist with housing searches, voucher applications, transitioning from institution to
community
• Member Advocates: assist with coordinating and access to community resources
• In-office care management support for provider or specialist visits
• Peer support specialist
• Disease management education
• Smoking cessation support services

The Z codes will be reimbursed when they are billed with code: G9919

Partial list of covered Z codes:

For full list of the covered Z codes that are covered, please click here.

Find this type of content useful, then follow my blog. Get your updated information about medical coding and billing guidelines, reimbursement/medical policies, prior authorization changes, etc.

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UHC Medicaid: Idaho: diabetic DME coverage change-benefit

Starting for DOS 4/1/26 and thereafter the following codes will be covered through the patient pharmacy benefit and no longer will be covered under patient medical benefit. For DOS 1/1/26 through 3/1/26- providers can still bill either through medical benefit or pharmacy benefit. Find this type of content useful? Follow my blog!

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Anthem BCBS: 32BJ fund new TPA and cards

As the new year starts so do the change of theember ID changes and or group numbers. Is your provider office aware of these changes? Please note that for any 32BJ members there is a new TPA, group#, member ID, and cards. Please note the new ID: Effective Jan 1,2026- new members ID prefix BJVBJ.…

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Are you leaving revenue on the table?

Aetna update! Is your practice compliant? Are you appending proper modifiers to radiology, diagnostic services and surgery services- when billed with the following ICD-10 codes: Z53.01, Z53.09, Z53.1, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9? As per Aetna- if the following modifiers are not billed on the claims for the above services with above named ICD-10 codes-…

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