Tag: #medicalbilling

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

Anthem BC/BS NY:MLTC Program updates 2025

Posted on by KR2Medical Billing

Are you a provider that provides services for MLTC members that have the MLTC Plan type through Anthem BCBS- then this blog post is for you!

The following changes take affect for any DOS after 3/1/25:

-MLTC member ID numbers

-Electronic funds transfer (EFT): EnrollSafe replaced Payspan as the EFT website.

-Availity Essentials replaced Payspan for provider remittances (ERA).

Authorizations for personal care services, social daycare, and meals will be issued in weekly units and will no longer contain a fixed daily schedule, allowing for greater flexibility in service provision and billing.


Claims-related updates:

-Access claim status information in Availity Essentials.

–Paper claims submission address


-Aligned claim timely filing guidelines.

-Value code and rate code are required for nursing home claims.

-Bill types and revenue codes were aligned for specific service.

-Check run days were changed to Wednesdays and Saturday

What is not affected:

-Authorization information is available on the legacy MLTC Provider Portal.

-Electronic claim submission — Payer ID 45302 for MLTC claims

-EDI claims submissions using Availity Essentials

-Claim dispute process

-Clinical appeal process

-The Care Management, Provider Services, and Provider Relations teams

For more information regarding these changes please visit: Anthem Provider Manual- MLTC

https://providers.anthem.com/new-york-provider/resources/manuals-policies-guidelines

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Posted in #unitedhealthcare, Insurance, Payer Updates, Prior Authorization Insurance Carrier Updates

UHC Knee/Hip Surgery documentation requirenments.

Posted on by KR2Medical Billing

Effective for services performed on Nov 1,2024 and there after, there will be new requirements for the prior authorization documentation applied to the Knee/Hip surgeries.

These changes/updates apply to self insured and fully insured plans nationwide.

Codes affected:

27445,27447, 27130 and 27132 

Knee Surgery Documentstion requirenments:

  1. Complete diagnostic imaging Reports: -Documented closure of skeletal plates (age less than 18 years)
    -Presence or absence of focal full-thickness articular cartilage defect
    -Size and location of focal cartilage defect
    -Outerbridge grade
    -Joint space and alignment
    -Ligament tear location and grade
  2. Diagnostic Images: – show the abnormality- MRI, Xray, Bone scan.
  3. Prior treatment documentation (prior year): -NSAIDs or acetaminophen ≥ 3 weeks*
    -PT or home exercise ≥ 12 weeks
    -Activity modification ≥ 12 weeks

*For TJR Knee ≥ 1 intra-articular corticosteroid injection may be used in place of NSAIDs.

For more information please click visit: https://www.uhcprovider.com/en/resource-library/news/2024/documentation-requirement-updates-total-joint-replacements.html

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Posted in #reimbursement, BCBS Empire NY, NY Providers, Training

Anthem BCBS (NY providers): PA/NP reimbursement

Posted on by KR2Medical Billing

According to Anthem BCBS (NY) starting for any DOS 11/1/24- the PA/NP will be updated to align with CMS guidelines.

Please note the following services will be eligible to be performed by the PAs/NPs and reimbursement reduction will apply:

– Preventative care services

-Radiology services

Services that are not going to be reimbursed separately:

-Drugs

-Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)

-Laboratory Services and Laboratory Screening Services

Billing: PA/NP has to bill with their own TIN and NPI number.

For the full policy please click here:https://www.anthembluecross.com/provider/policies/reimbursement/

CMS payment for NP/PA services:

-NP services: 85% of Physician Fee for outside of hospital setting or SNF, or 80% of lesser billed charge

-NP services : incident to services done by auxiliary personnel outside hospital or SNF setting – 85% of Physician Fee Schedule

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/advanced-practice-registered-nurses-aprns

-PA services: 85% of PFS- physician fee schedule.

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/physician-assistants-pas

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