Tag: #outpatienthospital

Posted in Insurance, Payer Updates, Training, Updates

Anthem BCBS (NY) Site of Care review for long-acting colony-stimulating factors, 06/01/2021

Posted on by KR2Medical Billing

This policy is for site of care medical necessity review and it only applies to administration performed in an outpatient hospital setting.

This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.

The medical necessity Review will be performed by AIM Specialty Health® (AIM).

AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Empire’s Medical Policy and Clinical UM Guideline page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.

The following codes apply to this policy:

To Submit a request for review:

Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:

  • Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity Web Portal at availity.com
  • Call the AIM Contact Center toll-free number: 1- 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

This review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com/provider.

**Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “site of care.”**

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Posted in In The Know Series, Insurance, Training

EmblemHealth Coverage Update-Certain Infusion medications-Effective 04/01/2020

Posted on by KR2Medical Billing

Accredo Convenient Care Program to start on 04/01/2020

Things to consider:

-Accredo’s Convenient Care Program is responsible for in-home fusion treatment for EmblemHealth members

-This update applies ONLY to members that are 21 years and older AND have an EmblemHealth Commercial Plan Coverage

-Coverage is for infusion medications that can be provided for patients in their homes or AIS (Ambulatory Infusion Suites/POS 12 or physicians office /POS 11

–After 04/01/2020-members do have an option to request ONE-TIME-ONLY refill of the specialty medicine at their CURRENT PROVIDER, if needed (check with customer service if Prior Auth would be required, if your Provider is in POS 19 or POS 22)

-Prior authorization is required in order to receive treatment in outpatient hospital setting. IF member is using Doctors Office of Campus POS19 or POS22 w/o an authorization, member will be responsible for the FULL AMOUNT OF the drug cost and treatment.

Transition Process:

1. An Accredo Representative will reach out to prescriber for a NEW prescription

2. Once a valid Prescription is received the Accredo Rep then will reach out to the member and schedule a delivery of medicine.

In Network Ambulatory Infusion Suites:

-Coram and Option Care infusion vendors have AIS throughout the country

Please contact your nearest Coram or Option Care location for more information

List of Specialty medications:

BIVIGAMHIZENTRA
CARIMUNE NFHYQVIA
CUVITRUINFLECTRA
FLEBOGAMMA 5&10%OCTAGAM
GAMMAGARD LIQUIDPANZYGA
GAMMAGARD S-DPRIVIGEN
GAMMAKEDREMICADE
GAMMAPLEXRENFLEXIS
GAMUNEX-C 

*Expeptions:

In order for the member to start or to continue the treatment in POS 19 or POS22 – the provider needs to submit clinical rationale and documentation for review.

AND

Member must to meet ONE of the following criteria:

-Pediatric Patient (under 21 years of age)

-Documented history of severe reaction, which is defined as anaphylactic reaction, to this medication or any constituent of it

-Known cardiac condition (e.g. symptomatic cardiac arrhythmias) or pulmonary condition (e.g. significant respiratory disease, serious obstructive airway disease, %FVC less or equal to 40%) that may increase a risk of an adverse reaction

-Documented intolerance to this medication requiring constant telemetry monitoring of vitals

-Unstable renal function which decreases the ability to respond to fluids

-Difficult of Unstable vascular access

-Unsafe home environment

-Acute mental status changes or cognitive conditions that impact the safety of infusion therapy

-No access to emergency services

Submitting an exception or request help to locate an approved home infusion vendor or AIS (ambulatory infusion suites):

-Contact EmblemHealth 888-447-0295

-Hours: 8am to 6pm

OR you can contact:

Accredo Phone#: 844-581-4862

Link to the full EmblemHealth Announcement: https://www.emblemhealth.com/providers/resources/toolkit/Reminder-Accredo-Convenient-Care-Program-Starts-April1-2020

Posted in Training, Updates

Empire NYSHIP- immunization claim submission changes for 2020

Posted on by KR2Medical Billing

Effective 01/01/2020- for dates on or after 01/01/2020-when NYSHIP Empire patients will get immunization services in outpatient Hospital (POS 22), Empire BCBS will consider these claims.

BEFORE 01/01/2020-claims need to be submitted to UHC, NYSHIP-s medical benefit administrator

Please remember all claims are subject to standard medical necessity guidelines and contract limitations.