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AMA terminology for diagnostic and procedure codes
|Primary Care Rate Increase Attestation Form Available on NYSDOH Website||6/4/13|
|Consult Codes Removed From Fee Schedule Effective November 1, 2010||2/13/12|
|Fair Health Replaces HIAA/Ingenix in 2011||2/07/11|
|Changes to the In-Office Testing List for CompreHealth, HIP and Vytra Plans||10/28/10|
|GHI Converts to Average Sales Price for Drugs Administered in Your Office|
Under the Affordable Care Act, eligible Primary Care Providers (PCPs) will be reimbursed at Medicare rates for certain primary care services rendered to EmblemHealth Medicaid managed care members. To be eligible for such reimbursement rates, you must start by submitting to the New York State Department of Health (NYSDOH) the appropriate New York State Medicaid Fee-For-Service and Managed Care Primary Care Rate Increase attestation form now available on the eMedNY website at the following links:
Once your application is approved and the NYSDOH determines how and when it will provide EmblemHealth with the funds to make these additional payments, we will inform you about how and when you can expect to receive payment from us.
Providers can sign up to receive ongoing updates on the PCRI program at: PCRI-L@listserv.health.state.ny.us and through the eMedNY listserv at https://www.emedny.org/Listserv/eMedNY_Email_Alert_System.aspx
To be consistent with Centers for Medicare & Medicaid Services guidelines, consultation codes are no longer reimbursable and have been removed from our prevailing plan fee schedule as of November 1, 2010. This change applies to all providers who received a notice, contract amendment, or both on or after July 2010. You may use Office Visit and Hospital Care codes, if applicable, to bill for your services instead of the removed consult codes. The affected consult codes are:
In 2011, FAIR Health will replace HIAA/Ingenix or similar language in our Prevailing Provider Fee Schedules, where documented in our provider agreements. In addition, our members have been notified that the FAIR Health database will replace the HIAA/Ingenix database for the purpose of calculating out-of-network claims.
To learn more about FAIR Health, please visit their Web site. We published on our Web site an explanation of FAIR Health for our members to help them understand in plain language what FAIR Health means for them. We invite you to review this explanation as well.
The In-Office Testing List, as published in the EmblemHealth Provider Manual, has been updated to allow certain in-office tests to be performed by additional types of specialists. It also includes an additional test that all practitioners may perform.
These changes are effective November 1, 2010, and are noted in bold in the list excerpt below:
|Excerpt from: In-Office Testing List - CompreHealth/HIP/Vytra Effective November 1, 2010|
|80100||Drug screen; multiple||Pain Medicine, Addiction Medicine|
|80101||Drug screen; single||Pain Medicine, Addiction Medicine|
|86485||Skin test; candida||Infectious Disease, Allergy/Immunology|
|86702-QW||OraQuick rapid HIV-2 antibody test|
|86735||Antibody; mumps||Infectious Disease, Allergy/Immunology|
*Please note: Most of the codes on the In-Office Testing List may be performed by all practitioners. However, some codes may only be performed by practitioners in the specialty type(s) listed within the “Specialty” column of the table.
Effective November 1, 2010 the following CPT-4 code will be added to the In-Office Testing List and may be performed by all specialty types:
86702-QW: OraQuick rapid HIV-2 Antibody Test
Effective December 31, 2009, GHI will begin reimbursing practitioners at a rate of approximately 13 percent over the average sales price (ASP). In addition, for many generic or branded equivalents, maximum allowable cost (MAC) reimbursement pricing will be employed and will generally pay more than 30 percent over the ASP for these products.
As generic or branded equivalents are made available for any particular injectable product and the acquisition costs for such products decrease, MAC pricing will adjust reimbursement to reflect changes in market pricing.
GHI's MAC methodology will apply to generics and therapeutic classes such as antiemetics, LHRH (luteinizing hormone-releasing hormone) agonists and certain chemotherapies. Quarterly updates will apply MAC pricing to additional therapeutic classes as new generics and therapeutic equivalents become available. Based on today's availability of generic and therapeutic equivalents, the MAC pricing changes will apply to the following HCPCS codes:
Should you have any questions related to this fee schedule change, please e-mail us at email@example.com if your practice is in New York City, Nassau, Rockland, Suffolk or Westchester counties. All other practices with questions may e-mail us at firstname.lastname@example.org.
|GHI and HIP are EmblemHealth companies. ©2013 EmblemHealth. All Rights Reserved. Last Updated 6-4-2013. Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information.|