• Tammy Bartlett

Excellus Pre-Authorization Tool; Medicaid E-Prescribing; NGS Pre-Payment Reviews

pen and paper


Excellus has as a new online pre-authorization tool called Clear Coverage. Clear Coverage includes an interactive question-and-answer medical review, based on Excellus BC/BS specific or InterQual evidence based criteria. This tool provides an instant decision regarding approval or pends for medical necessity review. Contact your Provider Relations Representative to set up training, or use Excellus’ training request form.


The Commissioner of Health has approved a new blanket waiver with respect to Medicaid’s electronic prescribing requirements. Effective March 26, 2017, the new waiver replaced and superseded the prior blanket waiver that was issued in March 2016. The Commissioner of Health will waive the requirements for electronic prescribing based on exceptional circumstances. Please visit the NYS Department of Health website for full details.


NGS will be conducting service-specific pre-payment reviews for CPT code 99214. The pre-payment review consists of a medical review of claims prior to payment. Request for records are automatically generated. The records/documentation requested should include the physician’s or the non-physician provider’s notes, orders, medication records, procedure/operative reports and diagnostic reports that will assist in supporting the services submitted. The notes are expected to be signed per signature guidelines. These reviews will help to identify common billing errors, develop educational efforts and prevent improper payments for CPT code 99214.


NGS has conducted a service-specific prepayment review for CPT codes 99354-99357, Prolonged Services. Prolonged (physician) services are payable when they are billed on the same day by the same physician as the companion E&M codes. Please note that Medicare requires face-to-face contact when prolonged (physician) services are reported.

The prepayment review resulted in some of the services being reduced or denied for the following reasons:

  • Direct face-to-face or floor/unit time was not supported.

  • Lacks content of prolonged service needed beyond the usual service of the E&M.

  • Prolonged service with over 50% of the total time of the face-to-face encounter is not being reported with the appropriate companion code (e.g. The E&M companion code for 99354 are the office or other outpatient visit codes of 99201-99205, 99212-99215. The E&M companion code for 99356 are the initial hospital care codes and subsequent hospital care codes of 99221-99223, 99231-99233).

  • Codes are being reported for family meetings with no appropriate E&M and the patient is not in attendance.

  • Diagnostic testing, (e.g. ophthalmological testing, neuropsychiatric testing, EKGs) is done at time of visit, but the time of the testing is not differentiated from the office visit and appears testing time is included in the reported prolonged time.

  • The rendering provider submitted on the claim was not the provider who actually rendered the service(s) per the submitted documentation.

  • No documentation was submitted for the requested date of service.

  • Documentation lacked the identification of the beneficiary.

  • Illegible documentation was submitted.

  • Duplicate services/claims were billed.

  • No E&M companion code was allowed on the same date of service.

  • The documentation was missing a date. Please note that a dictation date is not sufficient to support a date of service as to when a beneficiary was seen.

For more information regarding NGS’s billing recommendations for these codes, please visit NGS’s website. After accessing the website, click on:

→ Medical Policy and Review

→ Medical Review

→ Medical Review Focus Areas

→ Evaluation and Management – Jurisdiction K

→ CPT Codes 99354-99357

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