Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire. Please include this update with your Provider Manual for future reference.
Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Empire’s medical policies and clinical guidelines can be found at empireblue.com.
*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.
Clinical Guideline Updates
Revised Clinical Guidelines Effective 02-10-2020
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-BEH-14 - Intensive In-home Behavioral Health Services
- CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
As a result of coding updates in the claims system, the claim system edits for the clinical guideline listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.
Effective July 18, 2020, we will be implementing coding updates in the claims system for the following clinical guideline listed below which may result in not medically necessary determinations for certain services.
- CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
April 2020 Empire Provider News