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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Posted in BCBS Empire NY, Training, Updates

BCBS NY Medicaid: New Policy-Pass-through and Outside Laboratory billing

This reimbursement policy applies to Empire BCBS Health Plus members. The new reimbursement policy will become effective for DOS on 10/01/2021 and thereafter.


Empire BlueCross BlueShield HealthPlus does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.


Reimbursement:

Empire BCBS HealthPlus will reimburse 100% of the applicable fee schedule or contracted/negotiated rate to the diagnostic laboratory that is performing the test.


Coding: Modifier 90-definition

Modifier 90 is used when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

To read the complete reimbursement policy, please click here.


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Posted in Pharmacy (Various Insurance Payers), Training, Updates

NY/CA UHC CommunityHealthPlan: updated info for Xolair and Synagis auth, 04/01/2021

Starting 04/01/2021- the providers will need to request an authorization for Xolair and Synagris if they plan on billing through patient medical benefit. (Community Health Plan)

This change applies to providers in CA and NY (community health plans).

These requirements will apply whether members are new to therapy or have already been receiving these medications.

UHC will honor existing authorizations for Xolair until the end date on the authorization or the date the member’s eligibility changes.

Providers don’t need to submit a new prior authorization request for members who already have an authorization for Xolair on April 1, 2021.

You can submit prior authorization requests in the following ways:

  • Online: Use the Prior Authorization and Notification tool on Link. Go to UHCprovider.com/paan.
  • Call: Use the Provider Services phone number on the member’s health care identification card.