Posted in EmblemHealth NY, Training, Updates

EmblemHealth Commercial Plan: Infusion POS Policy update

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)

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Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth NY: Covid 19 Testing reimbursement policy update 06/01/22

If your office accepts emblemhealth members and provides COVID-19 testing services, then this blog post is for you!

COVID-19 Tests:

There are 3 main types of tests for COVD-19 (SARS-CoV-2) virus- diagnostic (viral), antigent test and serologic test (antibody.

A diagnostic (molecular and antigen tests tells if you likely have a current infection, by looking for parts of the virus itself in samples taken from an individual’s respiratory system secretion (eg. nasal swab).

A serologic, or anitybody test tells you if you have had a previous infection of COVID-19 by looking at the antibody responses in the blood sample. (In general a serologic test cannot be used for a diagnostic purposes. Antibodies can be detected in individuals that had a distant infection of the virus)


The following policy applies to Commercial, Medicare and Medicaid lines of business: via EmblemHealth Policy#: RPC20210016

Per the CDC, “Cliniciansshould use their judgment to determine if a patient hassigns orsymptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough) but some infected patients may present with other symptoms as well.”
▪ Symptomatic individual suspected of having COVID-19.
▪ Testing of asymptomatic patients used as part of a pre-surgical or facility pre-admission screening,
prior to an immunosuppressive procedure, or when a patient is admitted to a Skilled Nursing
Facility in accordance with CMS and CDC testing guidelines.
▪ Known or suspected prolonged, close contact, with an individual with a laboratory confirmed case
of COVID-19 as defined by CDC guidelines.
▪ Coronavirus COVID-19 (SARS-CoV-2) respiratory panel (up to 5 respiratory pathogens) test when
member has signs and symptoms of COVID-19.


SARS-CoV-2 Serology Testing
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) serology (antibody) testing may beconsidered a covered service when the following criteria are met:
▪ An individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, OR
• A licensed or authorized health care provider refers an individual for a COVID-19
diagnostic test. AND
▪ FDA approved or cleared or Emergency Use Authorization (EUA) AND
▪ Performed by a CLIA-accredited high or medium-complexity laboratory (per test Instructions for Use) AND
One of the following three conditions is present:
▪ Results of a molecular or antigen test is non diagnostic for COVID-19 and the results of the test will be used to aid in the diagnosis of a condition related to COVID-19 infection (e.g., Multisystem Inflammatory Syndrome [MIS]). OR
▪ Used as a method to support the clinical assessment of acute COVID-19 illness for persons who are being tested 3–4 weeks after illness onset, in addition to recommended direct detection methods such as polymerase chain reaction (PCR). OR
▪ Used as a method to help establish a clinical picture when patients have late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.


Coding/Billing Information:
Effective 6/1/2022 – EmblemHealth and ConnectiCare will amend the billing
instructions to align with CMS’ instructions on how to bill for COVID-19 test related
services. The plan will require the use of modifier CS when identifying services that
are related to the need determination for a COVID-19 test.

Partial List of CPT/HCPCS codes:

*NY Medicaid covered codes may differ and follow NYS guidelines
CPT/HCPCS Description
U0001* CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
U0002(QW) 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes(includes all targets), non-CDC
U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R
U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R
U0005- Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days from date and time of specimen collection.(List separately in addition to either HCPCS code U0003 or
U0004)
0224U -Antibody, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID19]),includes titer(s), when performed
0240U- Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected (Xpert® Xpress SARSCoV-2/Flu/RSV (SARS-CoV-2 & Flu Targets only), Cepheid)
0241U-Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected (Xpert® Xpress SARSCoV-2/Flu/RSV(all targets), Cepheid)
86328- Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

For a complete list of codes, please click here for the complete reimbursement policy.


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Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth NY Medicaid and HARP members: Non-Invasive Prenatal Trisomy Screening Expanded!

Effective 11/01/2021 coverage of non-invasive prenatal trisomy screening using cell-free fetal DNA (deoxyribonucleic acid) has been expanded to include pregnant members age 30 and older.

This benefit also will include twin pregnancies, but not higher multi-gestational pregnancies


Consistent with current policy, non-invasive prenatal trisomy screening will continue to be covered when at least one of the following criteria is met:

  • Either parent has a family history of aneuploidy in a first* or second** degree relative.
  • Standard serum screening or fetal ultrasonographic findings indicate an increased risk of aneuploidy.
  • Parent(s) have a history of a previous pregnancy with a trisomy.
  • Either parent is known to have a Robertsonian translocation.

Definitions:

*First degree relatives: Parents, children, siblings
** Second degree relatives: Grandparents, aunts and uncles, nieces and nephews, and grandchildren


Note: This is an update to the October 2014 Medicaid Update article titled NYS Medicaid Now Covers Non-invasive Prenatal Testing for Trisomy 21, 18 and 13.

You can find the updated version of this policy (NY Medicaid) here.  


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