Tag: #Medicaid

Posted in #unitedhealthcare, Training, Updates

NY UHC (Medicaid) Orthotics: added codes to prior auth list, 04/01/2021

Posted on by KR2Medical Billing

Starting 04/01/2021 the following codes will be added to NY Medicaid list of codes that require an authorization.

This change applies to the following UnitedHealthcare Community Plan members:

  • UnitedHealthcare Community Plan for Families (Medicaid)
  • UnitedHealthcare Community Plan Wellness 4 Me (HARP)
  • UnitedHealthcare Community Plan Essential Plan (EP)
  • UnitedHealthcare Community Plan ChildHealthPlus (CHP)
Posted in Insurance, Training, Updates

EmblemHealth (NY) COVID-19 Vaccine and Monoclonal Antibody Infusions Policy

Posted on by KR2Medical Billing

Effective 11/09/2020 the following are the guidelines for COVID-19 Vaccine and Monoclonal Antibody Infusions for various EmblemHealth Product lines:

  1. Commercial Plans- EmblemHealth will cover the costs that are associated with administration of COVID-19 vaccines, for In-Network and Out-of-network providers, during the national public health emergency period. Reimbursement will be based on CMS published rates. NY state-specific rules may also apply: Please click here for a NY DOH COVID-19 vaccine presentation.
  2. Medicare Advantage Plans- charges for administrating the COVID-19 vaccine should be billed to your local MAC (Part B). The MAC will reimburse claims for Medicare members with no cost share for the remainder of 2020 and through 2021 If the provider will bill the claims to EmblemHealth the charges will be denied and the provider will be informed that the charges need to be submitted to the local Part B MAC. (If you are a provider located in NY the local Part B MAC is NGS- national government services).
  3. Medicaid Plans- EmblemHealth will cover costs that are associated with administration of COVID-19 vaccines, for In-Network and Out-of-network providers, during the national public health emergency period. NY state-specific rules may also apply: Please click here for a NY DOH COVID-19 vaccine presentation.

Partial List applicable to this reimbursement policy:

For the complete policy and the complete list of applicable codes, please click here to visit the policy.

Posted in Training, Updates

EmblemHealth Commercial and Exchange Plans – order Prior Auths through Express Scripts

Posted on by KR2Medical Billing

Just a reminder to all of providers that accept EmblemHealth Commercial and Exchange Plans- starting 08/03/2020 Express Scripts will be responsible for utilization management of most specialty and step therapy drugs (specialty medications).

This change does NOT apply to EmblemHealth Medicaid and Medicare Plans or adult chemotherapy and supportive agents. Providers should follow the prior authorization guidelines through EmblemHealth. (Please see below)

EmblemHealth Commercial and Exchange Plans– Requesting an EPA (electronic Prior Authorization) Steps:

1. If your practice utilizes an EHR, you would be able to order it electronically.

2. You may also utilize: Covermymeds, Surescipts or ExpressPath- here you are able to create a free account and request an ePA.

Request Prior Auth by Phone & Fax:

1. Pharmacy Drug Reviews- phone 844-516-3324 (available 24/7/365) or by fax#: 877-251-5896

2. Medical Drug Reviews- phone 877-681-9866 (available 8am to 7pm EST) Monday through Friday, or by fax#: 866-896-1209

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Requesting Prior Authorizations for EmblemHealth Medicaid and Medicare Plans:

1. Specialty Drugs- phone 888-447-0295 (available 8am to 6pm, Monday through Friday), or fax# 877-243-4812

2. Pharmacy Drugs- phone 877-362-5670 (available 8am to 6pm, Monday through Friday) or fax# 877-300-9695

IMPORTANT: if your patient has received an Authorization Approval prior to 08/03/2020, from EmblemHealth- it is valid until the expiration date of the authorization. Subsequent requests have to go through Express Scripts NOT EmblemHealth. (Your claims will be denied if you do not request an authorization from Express Scripts after 08/03/2020 and beyond)

For the full provider announcement, please see the slideshow below.