Provider News CaliforniaApril 2021 Anthem Blue Cross Provider News - CaliforniaA key goal of Anthem Blue Cross’ (Anthem) provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Value Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various Value Based Programs (e.g., Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, etc.) (the “Programs”) quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value Based Program Providers may be referring, or plan to refer, their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs may result in their getting more referrals from Value Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.
Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.
Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.
Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.
1034-0421-PN-CA Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.
We encourage providers to utilize the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com/ca/ to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
1003-0421-PN-CA Having the common goal of reaching all Latinos in the US, Anthem, Inc., the Beckman Research Institute of City of Hope, the National Hispanic Medical Association, and Pfizer, Inc., announce the launch of Tomando Acción por Nuestra Salud/Taking Action for Our Health, a free interactive bilingual website aimed at eliminating health disparities in the Latino community. The website encourages preventive health screenings for cancer, emotional health, heart health, and prediabetes. It also provides tools to help people care for the emotional health of their families and themselves in the language of their preference.
The interactive website highlights the importance of health screenings, addresses barriers and provides information on access to low and no cost healthcare services in the community. The easy to use website, guides participants through four programs where they can learn about risk factors, take action to get screened, monitor their progress, and share their results with their doctors, health care teams or family and friends to let them know they are taking steps to protect their health and help encourage others to participate as well.
The website is not exclusive for Anthem members. Health care providers are encouraged to share the website with all of their Latino patients.
The website identifies four major targets of undue poor health outcomes for Latinos. In response, Tomando Acción por Nuestra Salud/Taking Action for Our Health strives to help increase cancer screening, screening for depression/anxiety-risk, heart diseases and prediabetes and provides tools to address emotional health. The website includes a 4-part workshop series “Compartiendo el Café y el Chocolate/Coffee and Chocolate” to help people care for the emotional health of their family and themselves. This is a program, specifically for Hispanics, that uses a holistic approach to emotional stability. It builds on cultural strengths to balance four key items—community, body, mind, and spirit.
To access Tomando Acción por Nuestra Salud/Taking Action for Our Health visit: Taking Action for Our Health.
1038-0421-PN-CA Healthcare and mental healthcare professionals have a vital role in identifying, treating, and addressing racial trauma and injustice, moving our communities towards racial equity, and improving the health and wellbeing of all Americans.
We can impact the injustice of racism together. Anthem has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to take on the challenge of facilitating conversations on racial injustice, trauma, and inequality among our providers and associates.
We are hosting Racial Equity forums on a quarterly basis to keep the conversation going. Please register for the next forum, Deconstructing Bias, to learn more about the impact of racism on healthcare and the people we serve, and what we can do about it.
In Pursuit of Racial Equity: Deconstructing Bias
Wednesday, June 9th, 2021 4:00 pm – 5:30 pm Eastern, (1:00 pm – 2:30 pm Pacific) Register today!
Our racial equity forums focus on:
- Exploring how racism takes shape in healthcare.
- Discussing how to identify racism in your practice and how to be an ally to your patients.
- Understanding the impact of prolonged exposure to racism on people of .
- Providing you with actionable resources to put an end to racism in your practice.
Since October 2020, Anthem has sponsored two virtual forums featuring healthcare professionals from Anthem and Motivo: Racial Trauma in America and The Road to Allyship: Playing Your Part in Racial Equity.
We know we are on the right track because the Racial Equity Forum participants say so.
- 90% received meaningful information about the influence that racism and white privilege may have on their perspectives and gained an understanding on what actions they can take to make a difference and be an ally.
- 86% obtained useful information and resources that will enhance their ability to serve patients.
- 75% agreed that the forum helped them understand a different perspective.
- 76% had some of their perspectives and beliefs challenged.
Systematic racism is a part of today’s healthcare system.
- US physicians underestimate the pain level of Black patients 47% of the time vs. 33.5% of the time for white patients (PNAS).
- Black women die from pregnancy or childbirth 243% more often than white women (CDC).
The first step to addressing racism is to recognize its existence, subtle or otherwise.
These conversations can be uncomfortable, but this is how you can do something about racial injustice now.
At Anthem, we are determined to reduce racism in our communities with your support and participation.
*Motivo is an independent company providing a virtual forum on behalf of Anthem.
1089-0421-PN-CA
In May 2020, the Centers for Disease Control (CDC) released a report that showed a drop in routine childhood vaccinations as a result of COVID-19; a result of stay at home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.
To encourage well-visits and vaccinations, here are some extra steps you can take, if you haven’t already, to make visits as safe as possible for both patients and staff. They include:
- Scheduling sick visits and well-child visits during different times of the day.
- Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms.
- Offering sick visits and well-child visits in different locations.
It’s important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.
Important update from The National Committee for Quality Assurance (NCQA) NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They reemphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning.
Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
Billing codes:
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
Billing Codes:
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
1080-0421-PN-CA The Centers for Medicare & Medicaid Services (CMS) has issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement Application Programming Interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates, that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS has identified Health Level 7® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.
Anthem Blue Cross’ (Anthem) Clinical Data Acquisition Group has integrated Admission, Discharge and Transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange can help Anthem:
- Better support members with care coordination and discharge planning – leading to healthier outcomes for our members – your patients.
- Proactively manage care transitions to avoid waste.
- Close care gaps and educate members about appropriate care settings to better manage out-of-pocket expenses.
Anthem would like to digitally exchange HLT ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real time HL7 ADT messaging data, or at least within 24-hours of admission, discharge or transfer, enables Anthem to most effectively manage care transitions.
Contact the Clinical Data and Analytics team to get started today. Email ADT_Intake@Anthem.com.
1081-0421-PN-CA Anthem Blue Cross (Anthem) and Availity are excited to announce the Prior Authorization/Referrals 278 and Inpatient Admission and Discharge Notification 278N 5010 transactions functionality.
Authorization and Referral Request (278)
Use this transaction to electronically submit authorization and referral requests. You have the option to transmit this transaction in real-time or batch mode, and you will receive confirmation numbers to validate receipt of request.
- An authorization is a review and approval of specific services
- A referral is used to refer a patient to a specialty provider
Hospital Admission Notification (278N)
Use this transaction to electronically submit hospital admission notifications between your facility and health plan. The EDI 278N is the easiest, most efficient way to communicate facility admissions. Just like the 278, you can also transmit in either batch or real-time format which includes the ability to update a previously submitted date.
What are your benefits for using these transactions?
- Streamline administrative tasks and increase productivity
- Reduce administrative costs through automation
- Increase data accuracy by reducing manual errors
- Confirm a notification of admission is on file in the form of a service reference number that is generated upon registration
- Submit notification of discharge
- Accomplish more with less ‒ fewer phone calls, faxes or keying
Getting Started
- If you use a clearinghouse or vendor work with them to ensure they have the capability to exchange these transactions.
- If you use practice management software have your Availity administrator use the following path to enroll:
- My Providers > Enrollment Center > Transaction Enrollment
Useful Documents
- Availity EDI Companion Guide communicates Availity-specific requirements and other information that supplements requirements and information already provided in standard EDI and HIPAA communications.
- Anthem specific companion guide communicates requirements for submitting these transactions. These are located on the company website at com/ca/provider/edi.
- The Availity Quick Start Guide will assist you with any EDI connection questions you might have.
If you need assistance, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 8 p.m. Eastern Time.
1082-0421-PN-CA As an Anthem Blue Cross (“Anthem”) participating provider, you may have received our prior correspondence, or read articles in Provider News on Anthem Cost Transparency. Transparency tools such as Anthem’s Find Care tool and others are available to members on anthem.com/ca and allow members to estimate their out-of-pocket impact and view the estimated costs for many procedures.
In our prior correspondence, we also enclosed a summary of the methodology used to generate the cost information housed in the National Consumer Cost Tool (NCCT), the source data used to display costs in Find Care. The treatment categories for which costs are displayed and the methodology are defined by the Blue Cross Blue Shield Association. As indicated in the correspondence, BCBS Axis (formerly NCCT) cost data is updated twice annually; the most recent update completed in November 2020, and the next update scheduled for May 2021. Please look for more information in Provider News (newsletter) posted the first of each month on anthem.com/ca.
As a reminder, Anthem provider costs are now available in a secure section of the Availity provider portal. Authorized representatives of participating facilities and professional practices can login to Availity at www.availity.com, and register to view the costs for their facility or practice. Costs will be made available to our participating providers no less than 30 days before they become available to our members on anthem.com/ca in the transparency tools such as Anthem Care Comparison.
You can review the methodology, or request a copy by sending an e-mail request to the Anthem California contract support team at CAContractSupport@anthem.com.
If your office or organization would prefer to provide an Internet Web site link on Anthem’s website where this cost information will be displayed, which provides a response to the cost information being displayed, please provide Anthem with this link within thirty (30) days of receiving the cost information from us.
1033-0421-PN-CA Information Center - Access important policies, forms and helpful resources
We're changing!
The Information Center is replacing the Education and Reference Center application in Payer Spaces on the Availity Portal. There you’ll find important policies, forms and helpful resources.
If you’re looking for specific education materials, we invite you to visit the Custom Learning Center in Availity, which was designed to offer education/training content and to be a learning environment. Content previously posted in the Communication & Education tab have now migrated there. Find the Custom Learning Center tool in Payer Spaces > Applications > Access the Custom Learning Center.
Locate the Information Center in Payer Spaces. Depending on your market, the Information Center contains a several sections:
- Administrative Support
- Behavioral Health
- Clinical Resources
- Medicaid
- Medicare
- Federal Employee Program (FEP)
To view content in both of these valuable tools, visit Payer Spaces today.
1060-0421-PN-CA ATTACHMENTS (available on web): Payer Spaces.png (png - 0.33mb) Did you know your Availity administrator for your organization is the key to opening doors to self-service transaction roles such as Electronic Data Interchange (EDI)? A role is a group of job functions, also known as permissions. Each role consists of one or more permissions. Assigning roles is part of the process when you add a new Availity user with the Add User feature.
What EDI roles do I need?
EDI Management - This role consists of the following permissions available under EDI File Management in the Availity menu:
- EDI Reporting Preferences– Specify the EDI batch report files you want users at your organization to receive, along with file formats and other reporting preferences.
- EDI Send and Receive Files– Review EDI batch report files for batch files submitted using Availity's EDI File Management feature. In addition, review payer responses to Availity Web-based claim forms submitted to payers that process claims in batches.
- File Restore– Restore archived EDI files to your ReceiveFiles
Set up EDI Reporting Preferences
Availity's batch EDI processing generates response files for each batch file that you submit. The administrator for an organization can set reporting preferences that specify which response files are generated. In the Availity Portal menu, click Claims & Payments > EDI Reporting Preferences.
Enroll for the Direct Data Entry Transaction
You must be assigned the Claims role to submit professional claims or encounters. If you cannot access the claim form, contact your administrator to assign the Claims role to you. Submit transactions through manual data entry in Availity Portal. In the Availity Portal menu, click Claims & Payments > Professional Claim/Facility Claim/Dental Claim < Confirm which organization and payer you would like to submit claims for and continue to complete the fields to be directed to the simple and time saving claim form to enter claim information.
Need More Help?
The EDI Connection Services Startup Guide is a helpful resource to help you get started, set up your EDI reporting preferences and submit transactions through manual data entry in Availity Portal.
Contact Availity
- Select Help & Training > Get Trained to display the Availity Learning Center (ALC) in a new browser tab. Search the catalog to locate and enroll in courses. Based on your needs.
- Select Help & Training > Find Help to display Availity Help in a new browser window. Use Contents to display topics. Depending on your needs, consider exploring these topics:
- Administrator
- Claim Submission
- Electronic Data Interchange (EDI)
- Glossary
- Select Help & Training > Availity Support to:
- Open a ticket to request support
- Get support via Chat
1061-0421-PN-CA
Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. Log on to the Anthem Blue Cross website: www.anthem.com/ca. Select Providers, under Communications go to Education and Training. Scroll down to view Training, Educational and Resource offerings.
1075-0421-PN-CA Anthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.
Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they are entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com.
1012-0321-PN-CA
The Blue Cross Blue Shield Association recently published an updated study1[i] that showed a downward trend in the physical health of millennials (those born between 1981 and 1996) driven largely by behavioral health conditions. There were notable increases in major depression (12%), alcohol use disorder (7%) and tobacco and substance use disorders (5%).
Millennials with behavioral health conditions were at twice the risk of having a chronic physical condition.
The study included the analysis of millennials’ medical claims over a five year period. Those with ongoing behavioral health conditions were twice as likely to have a chronic physical condition as their peers without a behavioral health diagnosis.
Behavioral health conditions driving adverse health for millennials
Reprinted from Blue Cross Shield Association’s 2019 report on the Health of Millennials.
It’s important to follow-up with your patients - millennial, Gen X, Gen Z or baby boomer, who are prescribed antidepressant medications or who have been hospitalized for mental illness or substance use disorders. Not only will patients have better behavioral health outcomes, their physical health could be significantly impacted as well. Follow these HEDIS® measures for additional guidance in closing the gaps in behavioral health conditions for all ages.
A note about telehealth
NCQA now accepts telehealth codes for behavioral health and some physical health measures. The modifiers 95 and GT are defined as telehealth services rendered via interactive audio and video telecommunications system. CPT Codes 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 98960-98962, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99409 and 99495-99496 may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95.
AMM - Antidepressant Medication Management (AMM): The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported:
- Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
- Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).
AIM Billing Codes:
- BH Outpatient CPT: 99078, 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99510 HCPCS: G0155, G0176-G0177, G0409, G0463, H0002, H0004, H0031, H0034-H0037, H0039-H0040, H2000, H2001, H2010-H2011, M0064, T1015
- Emergency Department CPT: 99281-99285 UB Rev: 0450-0452, 0456, 0459, 0981
- Major Depression ICD-10 CM: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9
- Telephone Visits CPT: 98966-98968, 99441-99443
- Telephone Modifier Value Set: 95 GT POS: 02
- Telehealth: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
- Telehealth modifier: 95 or GT
- Telehealth POS: 02
Note: not all CPT codes listed are eligible for reimbursement, please refer to your specific payment schedule for eligible CPT codes.
FUH - Follow-Up After Hospitalization for Mental Illness (FUH) - The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported:
- The percentage of discharges for which the member received follow-up within 30 days after discharge.
- The percentage of discharges for which the member received follow-up within 7 days after discharge.
The follow-up visits, within 7 days and 30 days after hospitalization can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUH Billing Codes:
- Follow-Up Visits CPT: 90791-2, 90832-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510 HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
- Mental Illness Diagnosis Codes ICD-10: F03.9x, F20-F25.xx, F28-F34.xx, F39-F45.xx, F48.xx, F50-F53.xx, F59-F60.xx, F63-F66.xx, F68-F69.xx, F80-F82.xx, F84.xx, F88-F93.xx, F95.xx, F98-F99.xx
- Telehealth visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
Telehealth modifier: 95 or GT Telehealth POS: 02
Note: not all CPT codes listed are eligible for reimbursement, please refer to your specific payment schedule for eligible CPT codes.
FUM - Follow-Up After Emergency Department Visit for Mental Illness (FUM) - The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:
- The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
- The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).
The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUM Billing Codes:
- Outpatient Follow-Up Visits CPT: 90791-2, 90832-4, 90836-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510
- HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
- Mental Illness Diagnosis Codes ICD-10:9x, F20-25.xx, F28-34. xx, F39-45.xx, F48.xx, F50-53.xx, F59-60.xx, F63-66.xx, F68-69.xx, F80-82.xx, F84.xx, F88-93.xx, F95.xx, F98-99.xx
- Intentional Self-Harm Diagnosis Codes ICD-10 example:92XA
- Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
- Telehealth modifier: 95 or GT
- Telehealth modifier POS: 02
Note: not all CPT codes listed are eligible for reimbursement, please refer to your specific payment schedule for eligible CPT codes.
FUA - Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA) - The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. Two rates are reported:
- The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
- The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).
The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUA Billing Codes:
- Initiation, Engagement and Treatment Follow-Up Visits CPT: 98960-2, 99078, 99201-5, 99211-5, 99241-5, 99341-50, 99384-7, 99394-7, 99401-4, 99408-9 99411-2, 99483, 99510
Alcohol Counseling or Other Follow-Up Visits CPT: 99408-9 HCPCS: G0396-7, G0443, H0005, H0007, H0016, H0022, H0050, H2035-6, T1006, T1012 AOD
- Medication Treatment HCPCS: G2067-77, G2080, G2086-7, H0020, H0033, J0570, J0571-5, J2315, Q9991-2, S0109
- Substance Use Disorder Diagnosis Codes ICD-10: F10-16.xx, F18-19.xx
- Telehealth modifier: 95 or GT
- Telephone visits: 98966 - 98968, 99441- 99443
- Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99408-99409, 98960-98962
- Telehealth modifier POS: 02
Note: not all CPT codes listed are eligible for reimbursement, please refer to your specific payment schedule for eligible CPT codes.
FUI – Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) - The percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:
- The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
- The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.
FUI Billing Codes:
- Opioid Abuse and Dependence ICD-10:10; F11.120; F11.121; F11.122; F11.129
- Other Drug Abuse and Dependence ICD-10:10; F12.120; F12.121; F12.122; F12.129
- Alcohol Abuse and Dependence ICD-10:10; F10.120; F10.121; F10.14; F10.150
- Telephone Visits CPT: 98966-98968; 99411-99443
- Online Assessments CPT: 98969-98972; 99421-99423; 99444; 99458
- IET Stand Alone Visits CPT: 98960-98962; 99201-99205; 99211-99215
Note: not all CPT codes listed are eligible for reimbursement, please refer to your specific payment schedule for eligible CPT codes.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
1Millennial Health: Trends in Behavioral Health Conditions. https://www.bcbs.com/the-health-of-america/reports/millennial-health-trends-behavioral-health-conditions
1079-0421-PN-CA When requesting CPAP/APAP/BIPAP, please do NOT use a NOC code, use the specific appropriate code for each durable medical equipment device. Beginning April 1, 2021, E1399 will no longer be part of AIM’s sleep therapy program, and should not be submitted to AIM for review for CPAP/APAP/BiPAP.
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The Special Investigations Unit (SIU) is tasked to conduct investigations involving allegations of fraud, waste and abuse, to work with our providers to resolve billing practice issues in order to reduce or eliminate future payment issues, and, where appropriate, to recover overpayments.
As part of Anthem Blue Cross’ (Anthem) role to safeguard our members and provide relevant information to providers we are relaying the following information regarding clinical guideline CG-LAB-11.
This document addresses routine testing of serum vitamin D levels in adults and children where there is an absence of clinical signs and symptoms of vitamin D deficiency or intoxication or conditions for which vitamin D supplementation may be recommended. Vitamin D testing is a non-invasive blood test which can aid in the identification and clinical management of individuals at-risk for vitamin D deficiency. Testing vitamin D levels in individuals with no known signs or symptoms of vitamin D deficiency or intoxication nor conditions for which vitamin D treatment is recommended is considered not medically necessary.
When services are Not Medically Necessary:
When the code describes a procedure specified in the Clinical Indications section as not medically necessary.
CPT Code
|
Description
|
82306
|
Vitamin D; 25 hydroxy, includes fraction(s), if performed [when specified as screening]
|
82652
|
Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed [when specified as screening]
|
0038U
|
Vitamin D, 25 hydroxy D2 and D3, by LCMS/MS, serum microsample, quantitative Sensieva Droplet 250H Vitamin D2/D3 Microvolume LC/MS Assay; InSource Diagnostics
|
ICD-10
|
Diagnosis including but not limited to the following:
|
Z00.00
|
Encounter for general adult medical examination without abnormal findings
|
Z00.129
|
Encounter for routine child health examination without abnormal findings
|
Z01.419
|
Encounter for gynecological examination (general) (routine) without abnormal findings
|
Further details regarding this policy can be found at https://www.anthem.com/ca/provider/policies/clinical-guidelines/
Laboratory Panel Testing
As a reminder, the use of a pre-determined panel of testing which includes tests for which there is no medical necessity for the individual patient should be avoided. Pre-determined laboratory panel testing for all patients regardless of individual patient presentation, does not address the individual needs of the patient and may be considered unsupported for purposes of payment. Please review any such panel testing that may include testing for Vitamin D to ensure that it is in fact appropriate for the patient in compliance with CG-LAB-11.
1063-0421-PN-CA
Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross (Anthem) contracted laboratories and identify that proper CPT codes to use.
Contact your Anthem Network Relations representative if you need additional information or visit anthem.com/coronavirus/providers.
COVID-19 testing coding guidelines
- For a new or established patient, CPT code 99211 would be appropriate if patient is being seen for no other services besides a specimen collection.
- For a patient assessment in addition to a specimen collection it is appropriate to bill the applicable E&M service, CPT codes 99202-99215. Specimen collection is a component of the E&M service and not separately reimbursable.
- Effective April 1, 2021, CPT codes G2023 and G2024 are appropriate when billed by clinical laboratories only and are not appropriate for provider practices.
Refer patients to anthem.com/coronavirus to find convenient testing locations
If an Anthem member requests a COVID-19 test, you may refer them to anthem.com or the Sydney Health mobile app to find testing locations near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:
- Appointments or walk-ins.
- Drive-through service.
- Rapid test results.
- Antibody testing.
- Testing for children.
Send swab tests to Anthem contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high value health care.
Consider Antigen testing when rapid test results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), e.g. PCR. Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individual within the first five to seven days of symptoms when virus replication is at its highest.
Antigen tests can be used to detect current infection, are relatively easy to use, and most can provide point-of-care testing results. The Centers for Disease Control and Prevention (CDC) notes that proper interpretation of antigen test results (and confirmatory testing with NAAT when indicated) is important for accurate clinical management of patients with suspected COVID-19; more information can be found here.
The CDC notes that when molecular tests are unavailable or rapid turnaround time is needed, antigen tests can generally be used for diagnosis of COVID-19.
Antigen tests are typically less sensitive, and clinicians should interpret negative results carefully. When symptoms are present or a high clinical suspicion exists, negative antigen tests should be confirmed with a molecular test.
When antigen tests are used in symptomatic patients, positive antigen tests can be interpreted as indicative of SARS-CoV-2 infection and do not usually require follow-up testing.
Consider using COVID-19 and flu combination testing when appropriate
According to the CDC, clinicians should consider testing for other causes of respiratory illness, including infections such as influenza, when clinically appropriate.
1099-0421-PN-CA
Reveleer is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers and ask that you respond to the detailed requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe. Reveleer will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary). We ask that you please promptly comply within five (5) business days of the record requests. If you have any questions, you can reach a Reveleer representative by calling 1-855-454-6182 or contact Ify Ifezulike with Blue Cross Blue Shield Federal Employee Program at 1-202-626-4839. 1091-0421-PN-CA In the February 2021 edition of Provider News, we announced updates to the formulary lists for Commercial health plans effective April 1, 2021.
Be advised that this is the link to the correct summary of formulary changes. Please disregard the list we published in the February article.
We apologize for any inconvenience this may have caused.
1113-0421-PN-CA For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacyinformation. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
1037-0421-PN-CA PCPs and their qualified staff are required to implement tobacco cessation interventions as outlined in the California Department of Health Care Services All Plan Letter 16-014 dated November 30, 2016. These interventions include:
- Conducting initial and annual assessments of all members, of any age, who use tobacco products or are exposed to tobacco smoke and documenting this information in the member’s medical record. Per the United States Preventive Services Task Force recommendations, this can be accomplished by instituting a tobacco user identification system by:
- Using the Staying Healthy Assessment or other Individual Health Education Behavior Assessments.
- Adding tobacco use as a vital sign in the chart or electronic health record, or by use of the
ICD-10 codes in the medical record to record tobacco use. Refer to the Coding Guide for Tobacco Use for codes that can be used.
- Placing a stamp or sticker on the chart when the member indicates he or she uses tobacco.
- Prescribing FDA-approved tobacco cessation medications to nonpregnant adults of any age. Members enrolled in Medi-Cal will be covered for all FDA-approved tobacco cessation medications for adults who use tobacco products. This includes over‑the‑counter medications with a prescription from the provider.
- Referring tobacco users of any age to available individual, group and telephone counseling. Anthem Blue Cross (Anthem) members qualify for four counseling sessions, each for a minimum of 10 minutes, for at least two separate quit attempts each year without prior authorization. Providers can:
- Use the 5A’s model or other validated behavior change model when counseling members.
- Refer a member to the CA Smokers Helpline at 1-800-NO-BUTTS (1‑800‑662‑8887) or another equivalent line. The CA Smokers Helpline is available in various languages.
- Refer to available community programs. For help locating community programs, use the Health Education & Cultural and Linguistic Referral Form located on the provider website at https://providers.anthem.com/ca > Patient Care > Primary Care > Health education classes.
- Asking all pregnant women if they use tobacco or are exposed to tobacco smoke. If they smoke, offer at least one face-to-face counseling session per quit attempt and refer to a tobacco cessation quit line. Counseling services will be covered for 60 days post‑delivery. Smoking cessation medications are not recommended during pregnancy.
- Providing education, including brief counseling, to school-age children and adolescents to prevent initiation of tobacco.
Anthem will monitor provider performance in implementing these tobacco cessation interventions through various processes comprised of medical record review, facility site review, and review of medical or pharmacy claims data.
If your office would like tobacco education materials or more information about the revised policy letter, please call the regional health plan office:
- Northern region: 1-888-252-6331
- Central region: 1-559-353-3500
- Southern region: 1-818-291-6914
What is happening?
Anthem Blue Cross (Anthem) is excited to notify providers of upcoming improvements to our platform for utilization review. These changes will be transparent to members and providers, and we are optimistic they will improve our ability to serve our members better by giving our associates easier and quicker access to necessary resources. The new platform also provides improved system capabilities, which will allow associates to perform their job functions with increased efficiency. Our goal is to have Anthem associates begin using the new Anthem Care Management System (ACMS) beginning in the first quarter of 2021.
What does this mean for you?
As a provider and/or representative managing and requesting authorizations:
- Nothing will change as it relates to how you request services for your members.
- Nothing will change with how you submit claim requests.
- The new ACMS authorization number will have a UM prefix. Example UM1234567
- If you have an existing authorization number, it will be valid and accessible after systems change.
- If you have both an existing authorization number and an ACMS authorization number with a UM prefix, either can be used as a reference for the requested service(s).
- After the new system implementation, letter correspondences will only display the ACMS authorization number.
- Providers may continue to use either system generated authorization numbers or member demographics (for example, name, date of birth, Member/Subscriber ID, Medicaid ID) to search authorization details.
- For Electronic Visit Verification (EVV) Providers: The ACMS number may not be viewable in the EVV system. If you are searching for your authorization, please use the other search options provided by the EVV vendor to locate your authorization outside of the ACMS number.
We are here to help!
If you have questions or concerns regarding an authorization for a requested service, you may call one of our Medi-Cal Customer Care Centers
- 1-800-407-4627 (outside L.A. County)
- 1-888-285-7801 (inside L.A. County)
Effective for dates of service on and after June 1, 2021, Anthem Blue Cross will include the specialty pharmacy drugs and corresponding codes from current Clinical Criteria noted below in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal, in addition to the current medical necessity review.
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS codes
|
ING-CC-0182
|
Preferred
|
Infed
|
J1750
|
ING-CC-0182
|
Preferred
|
Venofer
|
J1756
|
ING-CC-0182
|
Preferred
|
Ferrlecit
|
J2916
|
ING-CC-0182
|
Nonpreferred
|
Injectafer
|
J1439
|
ING-CC-0182
|
Nonpreferred
|
Feraheme
|
Q0138 (non-ESRD use)
|
ING-CC-0182
|
Nonpreferred
|
Monoferric
|
J1437
|
The Clinical Criteria is publicly available on our provider website. Visit https://www.anthem.com/ms/pharmacyinformation/Agents-for-Iron-Deficiency-Anemia.pdf for the specific Clinical Criteria.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call one of our Medi-Cal Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County). On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
June 1, 2021
|
ING-CC-0185*
|
Oxlumo (lumasiran)
|
New
|
June 1, 2021
|
ING-CC-0184*
|
Danyelza (naxitamab-gqgk)
|
New
|
June 1, 2021
|
ING-CC-0154
|
Givlaari (givosiran)
|
Revised
|
June 1, 2021
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
June 1, 2021
|
ING-CC-0002
|
Colony Stimulating Factor Agents
|
Revised
|
June 1, 2021
|
ING-CC-0032*
|
Botulinum Toxin
|
Revised
|
April is National Defeat Diabetes month. One way we can reach this goal is to understand and address how adverse childhood events (ACEs) — or events prior to the age of 18 that lead to toxic stress — affect the prevalence of and how patients deal with their diabetes. Data shows that 62% of Californians have experienced at least one ACE in the form of abuse, neglect or household dysfunction; 16% have experienced four or more in their childhood. Research has shown that people with four or more ACEs are 1.4 times as likely to have diabetes, as well as be less treatment-compliant. Those with a higher ACEs score are also at higher risk for 9 of the 10 leading causes of death in the United States. This is why the California Surgeon General has made it a priority to start screening for ACEs during regular doctor appointments for both adults and children and then connecting identified Californians with the proper resources to lower their level of risk. The screenings and two-hour training, including two CME or MOC credits, are all provided online for free. Once this training is completed, Medi-Cal Managed Care providers can be reimbursed for each screening done and can help their patients live longer, healthier lives. For more information, check out https://www.acesaware.org. Health education classes are available at no charge to Anthem Blue Cross (Anthem) members enrolled in Medi-Cal Managed Care (Medi-Cal) and are accessible on self-referral or referral by Anthem network providers. Typically, these classes take place with our hospital and community organization partners; however, one-on-one counseling with a certified health educator is also available.
Class availability varies by county. Topics include the following:
- Asthma management
- Childbirth/Lamaze/prenatal education
- Diabetes management
- Injury prevention
- Nutrition, obesity and weight management
- Parenting/well child
- Smoking cessation/tobacco prevention
- Substance abuse
To refer a member to a health education class, just fill out the Health Education & Cultural and Linguistic Referral Form located on the provider website at https://providers.anthem.com/ca > Patient Care > Primary Care > Health education classes.
Health education materials
Anthem has an extensive selection of health education materials in both English and Spanish for
providers and members. Providers can access health education information through the provider website by selecting the Health Education Programs option in the Provider Support portal or by following this link: https://mss.anthem.com/ca/pages/health-wellness.aspx. Providers can also request additional health education materials through their Network Relations or Quality Management representatives:
- Southern regional office: 1-818-291-6914
- Central regional office: 1-559-353-3500
- Northern regional office: 1-888-252-6331
Health education materials may be translated into additional languages on request. They are also available in alternative formats, including Braille, large print and audio. Contact the Customer Service number on the back of the member card to request these formats. Translations and alternative formats are free of charge.
Free language assistance programs
Our members count on our providers for medical care and treatment; however, they may experience language barriers, which make it difficult to ask questions or communicate their concerns. Anthem is committed to reducing the impact of language barriers for our Medi-Cal patients to obtain language assistance. Providers must notify members of the availability of interpreter services and strongly discourage the use of friends and family, particularly minors, to act as interpreters. Under the federal guidance, published as section 1557 of the Affordable Care Act, providers are required to use qualified interpreters while interacting with members with limited English proficiency. To obtain free interpreting services, please call one of our Customer Care centers:
- L.A. Care: 1-888-285-7801 (TTY 711)
- Medi-Cal: 1-800-407-4627 (TTY 1-800-735-2922) (TTY 711)
It is important that you or your office staff document the member’s language, any refusal of interpreter services, and requests to use a family member or friend as an interpreter in the member’s medical record. Request/Refusal of Interpreter Services forms are available in threshold languages on the Free Interpreting Services page of our website, located at: https://providers.anthem.com/california-provider/resources/provider-training-academy.
During regular business hours, providers and members may contact the Medi-Cal Customer Care
Center using the number located on the back of the member’s ID card. After hours, the
24/7 NurseLine is available at 1-800-224-0336. When requesting interpreter assistance:
- Give the customer care associate the member’s ID numbe
- Explain the need for an interpreter and the language required.
- Wait on the line while the connection is mad
- Once connected, the interpreter, an Anthem associate or nurse, introduces the Medi-Cal member, explains the reason for the call and begins the dialogue.
Providers and members may contact the Medi-Cal Customer Care Center to schedule face-to-face interpreter services for medical appointments during regular business hours. Three business days in advanced notice is required to schedule face-to-face interpreter services. A 24-hour cancellation is required. Providers may also schedule face-to-face interpreter services by sending an email to ssp.interpret@anthem.com and typing secure in the subject line. This is a secure email requiring registration.
Members with hearing or speech impairments may use the Medi-Cal Customer Care Center TTY number during regular business hours. After hours, the 24/7 NurseLine TTY number may be used. Members can also use the state relay service line by dialing 711. Customer Care Center associates can also assist non-TTY users by contacting those who only use TTY equipment, such as providers needing to contact members with TTY assistive devices.
Members may request health plan materials in alternative formats such as Braille, large print, audio CD, verbal interpretations and non-English languages at no cost by contacting the Medi-Cal Customer Care Center number located on the back of their ID cards. Medi-Cal Managed Care (Medi-Cal) members at risk for type 2 diabetes will now have access to the Centers for Disease Control and Prevention (CDC) Diabetes Prevention Program (DPP). DPP has been proven by the National Institute of Health (NIH) in a randomized controlled trial to greatly reduce the progression of prediabetes to type 2 diabetes.1 Services are delivered by trained lifestyle coaches and organizations recognized by the CDC.
The DPP is a year-long program that consists of weekly sessions with a lifestyle coach for the first six months and monthly maintenance sessions for the latter six months. Sessions can be held in a group classroom setting or online. Participants will learn realistic lifestyle changes emphasizing weight loss through exercise, healthy eating and behavior modification.
Members can determine their eligibility for DPP and enroll through our program administrator, Solera Health, by visiting www.solera4me.com/AnthemBC_MediCal to take the online assessment or by calling 1-844-612-2949 (TTY 711), Monday through Friday from 6 a.m. to 6 p.m. PT.
Criteria for eligibility include:
- At least 18 years of age
- BMI of 25 or greater
- If member is of Asian descent, a BMI of 23 or greater is required.
- Blood screening (optional, if available):
- Hemoglobin A1C: 5.7% to 6.4%
- Fasting plasma glucose: 100 to 125 mg/dL
- Oral Glucose Tolerance Test: 140 to 199 mg/dL
- Exclusions include no previous diagnosis of end-stage renal disease or type 1 or type 2 diabetes; not pregnant (previous gestational diabetes is not an exclusion)
How to become a DPP provider with the Department of Health Care Services (DHCS):
Enrolled Medi-Cal providers should have one of the following provider types and will need to submit the Medi-Cal Supplemental Changes Form (DHCS 6209) to DHCS for approval:
- Home health agency
- Physician group
- Physician
- Indian Health Services
- Rural health clinic
- Community hospital (outpatient)
- County hospital (outpatient)
- DPP suppliers
Once the eligible Medi-Cal provider is approved to become a DPP provider, the provider will receive a newly established category of service (COS) containing the DPP billing codes, as outlined in the request for outsourcing. Only enrolled and eligible Medi-Cal providers who have the DPP COS may bill for DPP services.2
To get started, refer qualified patients today to www.solera4me.com/AnthemBC_MediCal!
References:
1 https://www.cdc.gov/diabetes/prevention/prediabetes-type2/preventing.html.
2 https://www.dhcs.ca.gov/services/medi-cal/Documents/DPP_OIL_Enclosure_A_Webpage.pdf. The Department of Health Care Services (DHCS) requires managed care health plans and their contracted providers to implement the age-appropriate Staying Healthy Assessment (SHA) questionnaires.
With many offices now using electronic medical records (EMRs), providers can:
- Scan the SHA to use it as an EMR.
- Add the exact SHA questions into an EMR.
- Use the SHA in a different electronic or assessment tool format.
- Use another assessment tool such as Bright Futures.
Anthem Blue Cross staff will:
- Work with your office either in-person or through e-mail correspondence to review printed screen shots of the electronic SHA to ensure all information from the questionnaires are incorporated word-for-word.
- Confirm that any other assessment tools that offices wish to use include the information that’s on the SHA.
- Submit the appropriate notification form to DHCS at least one month prior to office implementation as required along with the printed screen shots.
DHCS requires that providers must first notify the health plans by the use of either the SHA Electronic or Other Format Notification Form or Use of Bright Futures Notification Form. These forms can be obtained by calling your local regional health plan at the appropriate phone number below:
- Northern region: 1-888-252-6331
- Central region: 1-559-353-3500
Southern region: 1-818-291-6914 Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.
We encourage providers to use the online Provider Maintenance Form to notify us about your telehealth services, and we will add a telehealth indicator to your online provider directory profile.
Visit https://www.anthem.com/ca/medicareprovider to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions. Welcome to the 2021 In-Office Assessment (IOA) program. The IOA program is designed to help providers ensure that all active conditions are continuously being addressed and documented to the highest level of specificity for all Medicare Advantage plan patients of providers participating in the program. This program is designed to help improve all patient quality of care (preventive medicine screening, managing chronic illness and prescription management), as well as care for older adults when generated for a Special Needs Plan member.
If you are interested in learning about the electronic modalities available, please contact your representative or the Optum* Provider Support Center at 1-877-751-9207, Monday through Friday, from 5 a.m. to 4 p.m. Pacific time.
Success stories
Below are some achievements that Anthem Blue Cross (Anthem) was able to accomplish with provider groups through the IOA program:
- As a result of leveraging different types of resources offered by the IOA program (for example, technology), providers’ offices were able to see an increase in staff productivity.
- Providers who have taken advantage of the IOA program resources have seen an increase in their documentation and coding accuracy.
COVID-19 update
Anthem knows this is a difficult time for everyone, as the situation continues to evolve each day. Anthem has considered the severity of the situation and is following CDC Guidelines. For the IOA program, all nonessential personal are required to work with provider groups telephonically/electronically until further notice.
Anthem continues to evaluate the situation and guidelines and will keep you notified of any changes. If you have any questions or concerns about the IOA program and COVID-19 updates, please call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 5 a.m. to 4 p.m. Pacific time.
Dates and tips to remember:
- To review their population as soon as possible, Anthem strongly encourages participating providers to deliver and continually maintain proper care management, as well as care coordination of their patient population. This will further ensure the current and active conditions that impact patient care, treatment and/or management are continually addressed.
- At the conclusion of each office visit with the patient, providers participating in the IOA program are asked to complete and return a patient assessment. The assessment should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2021 version of the assessment for encounters that take place on or before December 31, 2021; Anthem will accept the 2021 version of the assessment for 2021 encounters until midnight January 31, 2022.
- If not already submitted, participating providers are required to submit an Account Setup Form, W-9 and completed direct deposit enrollment by March 31, 2022. Participating providers should call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 5 a.m. to 4 p.m. Pacific time, if they have any questions regarding this requirement. Failure to comply with this requirement will result in forfeiture of the provider payment for submitted 2021 assessments, if applicable.
Questions
If you have questions about this communication or the IOA program, please contact your representative or the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 5 a.m. to 4 p.m. Pacific time.
517440MUPENMUB Anthem Blue Cross (Anthem) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to better healthcare experiences for consumers.
Effective for dates of service on or after July 1, 2021, providers for our Medicare Advantage plan members covered by Anthem will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications, listed below. Reviews for these oncology drugs will continue to be administered by the reviewing company, either AIM Specialty Health®* or IngenioRx.*
Providers will be asked whether or not they will accept the dose reduction at the initial review point in the prior authorization process. Within the provider portal, a pop-up question will appear related to dose reduction. If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning. For requests made outside of the provider portal (for example, called-in or faxed-in prior authorization requests), the same questions will be asked by the registered nurse or medical director who is reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.
The dose reduction questions will appear only if the originally requested dose is within 10% of the nearest whole vial. This threshold is based on current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) that it is appropriate to consider dose rounding within 10%. HOPA recommendations can be found here.
The Voluntary Dose Reduction Program only applies to specific oncology drugs, listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy and Clinical Utilization Management Guidelines page at https://www.anthem.com/ca/medicareprovider.
Drug name
|
HCPCS code
|
Drug name
|
HCPCS code
|
Abraxane (paclitaxel protein-bound)
|
J9264
|
Istodax (romidepsin)
|
J9315
|
Actimmune (interferon gamma-1B)
|
J9216
|
Ixempra (ixabepilone)
|
J9207
|
Adcetris (brentuximab vedotin)
|
J9042
|
Jevtana (cabazitaxel)
|
J9043
|
Alimta (pemetrexed)
|
J9305
|
Kadcyla (ado-trastuzumab emtansine)
|
J9354
|
Asparlas (calaspargase pegol-mknl)
|
J9118
|
Keytruda (pembrolizumab)
|
J9271
|
Avastin (bevacizumab)
|
J9035
|
Kyprolis (carfilzomib)
|
J9047
|
Bendeka (bendamustine)
|
J9034
|
Lartruvo (olaratumab)
|
J9285
|
Besponsa (inotuzumab ozogamicin)
|
J9229
|
Lumoxiti (moxetumomab pasudotox-tdfk)
|
J9313
|
Blincyto (blinatumomab)
|
J9039
|
Mylotarg (gemtuzumab ozogamicin)
|
J9203
|
Cyramza (ramucirumab)
|
J9308
|
Neupogen (filgrastim)
|
J1442
|
Darzalex (daratumumab)
|
J9145
|
Oncaspar (pegaspargase)
|
J9266
|
Doxorubicin liposomal
|
Q2050
|
Opdivo (nivolumab)
|
J9299
|
Elzonris (tagraxofusp-erzs)
|
J9269
|
Padcev (enfortumab vedotin-ejfv)
|
J9177
|
Empliciti (elotuzumab)
|
J9176
|
Polivy (polatuzumab vedotin-piiq)
|
J9309
|
Enhertu (fam-trastuzumab deruxtecan-nxki)
|
J9358
|
Rituxan (rituximab)
|
J9312
|
Erbitux (cetuximab)
|
J9055
|
Sarclisa (isatuximab-irfc)
|
J9999
|
Erwinase (asparginase)
|
J9019
|
Sylvant (siltuximab)
|
J2860
|
Ethyol (amifostine)
|
J0207
|
Treanda (bendamustine)
|
J9033
|
Granix (tbo-filgrastim)
|
J1447
|
Vectibix (panitumumab)
|
J9303
|
Halaven (eribulin mesylate)
|
J9179
|
Yervoy (ipilimumab)
|
J9228
|
Herceptin (trastuzumab)
|
J9355
|
Zaltrap (ziv-aflibercept)
|
J9400
|
Imfinzi (durvalumab)
|
J9173
|
|
|
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Note: In some plans, dose reduction to nearest whole vial or waste reduction may be the term used in benefit plans, provider contracts or other materials instead of or in addition to dose reduction to nearest whole vial. In some plans, these terms may be used interchangeably. For simplicity, we have uses dose reduction (to nearest whole vial).
* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross. IngenioRx, Inc. is an independent company providing some utilization review services on behalf of Anthem Blue Cross. 517400MUPENMUB
On June 18, 2020, August 21, 2020, and November 20, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
March 26, 2021
|
ING-CC-0183*
|
Sogroya (somapacitan-beco)
|
New
|
March 26, 2021
|
ING-CC-0148*
|
Agents for Hemophilia B
|
Revised
|
March 26, 2021
|
ING-CC-0149*
|
Select Clotting Agents for Bleeding Disorders
|
Revised
|
March 26, 2021
|
ING-CC-0065
|
Agents for Hemophilia A and von Willebrand Disease
|
Revised
|
March 26, 2021
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
March 26, 2021
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
Revised
|
March 26, 2021
|
ING-CC-0121*
|
Gazyva (obinutuzumab)
|
Revised
|
March 26, 2021
|
ING-CC-0048 *
|
Spinraza (nusinersen)
|
Revised
|
March 26, 2021
|
ING-CC-0002*
|
Colony Stimulating Factor Agents
|
Revised
|
March 26, 2021
|
ING-CC-0034*
|
Hereditary Angioedema Agents
|
Revised
|
March 26, 2021
|
ING-CC-0041*
|
Complement Inhibitors
|
Revised
|
March 26, 2021
|
ING-CC-0071*
|
Entyvio (vedolizumab)
|
Revised
|
March 26, 2021
|
ING-CC-0064*
|
Interleukin-1 Inhibitors
|
Revised
|
March 26, 2021
|
ING-CC-0042*
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
March 26, 2021
|
ING-CC-0066*
|
Monoclonal Antibodies to Interleukin-6
|
Revised
|
March 26, 2021
|
ING-CC-0050*
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
March 26, 2021
|
ING-CC-0078*
|
Orencia (abatacept)
|
Revised
|
March 26, 2021
|
ING-CC-0063*
|
Stelara (ustekinumab)
|
Revised
|
March 26, 2021
|
ING-CC-0062*
|
Tumor Necrosis Factor Antagonists
|
Revised
|
March 26, 2021
|
ING-CC-0003*
|
Immunoglobulins
|
Revised
|
March 26, 2021
|
ING-CC-0039*
|
GamaSTAN [immune globulin (human)]
|
Revised
|
March 26, 2021
|
ING-CC-0053
|
Injectable Hydroxyprogesterone for Prevention of Preterm Birth
|
Revised
|
March 26, 2021
|
ING-CC-0073*
|
Alpha-1 Proteinase Inhibitor Therapy
|
Revised
|
March 26, 2021
|
ING-CC-0075
|
Rituximab Agents for Non-Oncologic Indications
|
Revised
|
March 26, 2021
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
March 26, 2021
|
ING-CC-0027*
|
Denosumab Agents
|
Revised
|
March 26, 2021
|
ING-CC-0019*
|
Zoledronic Acid Agents (Reclast, Zometa)
|
Revised
|
March 26, 2021
|
ING-CC-0011*
|
Ocrevus (ocrelizumab)
|
Revised
|
March 26, 2021
|
*ING-CC-0174*
|
Kesimpta (ofatumumab)
|
Revised
|
517460MUPNMUB On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
April 8, 2021
|
ING-CC-0185*
|
Oxlumo (lumasiran)
|
New
|
April 8, 2021
|
ING-CC-0184*
|
Danyelza (naxitamab-gqgk)
|
New
|
April 8, 2021
|
ING-CC-0154
|
Givlaari (givosiran)
|
Revised
|
April 8, 2021
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
April 8, 2021
|
ING-CC-0002
|
Colony Stimulating Factor Agents
|
Revised
|
April 8, 2021
|
ING-CC-0032*
|
Botulinum Toxin
|
Revised
|
April 8, 2021
|
ING-CC-0015
|
Infertility and HCG Agents
|
Revised
|
517445MUPENMUB Anthem Blue Cross (Anthem) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to better healthcare experiences for consumers.
Effective for dates of service on or after July 1, 2021, providers for our Medicare Advantage plan members covered by Anthem will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over [40] oncology medications, listed below. Reviews for these oncology drugs will continue to be administered by the reviewing company, either AIM Specialty Health®* or IngenioRx.*
Providers will be asked whether or not they will accept the dose reduction at the initial review point in the prior authorization process. Within the provider portal, a pop-up question will appear related to dose reduction. If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning. For requests made outside of the provider portal (for example, called-in or faxed-in prior authorization requests), the same questions will be asked by the registered nurse or medical director who is reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.
The dose reduction questions will appear only if the originally requested dose is within 10% of the nearest whole vial. This threshold is based on current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) that it is appropriate to consider dose rounding within 10%. HOPA recommendations can be found here.
The Voluntary Dose Reduction Program only applies to specific oncology drugs, listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy and Clinical Utilization Management Guidelines page at https://providers.anthem.com/ca.
Drug name
|
HCPCS code
|
Drug name
|
HCPCS code
|
Abraxane (paclitaxel protein-bound)
|
J9264
|
Istodax (romidepsin)
|
J9315
|
Actimmune (interferon gamma-1B)
|
J9216
|
Ixempra (ixabepilone)
|
J9207
|
|
|
|
|
Adcetris (brentuximab vedotin)
|
J9042
|
Jevtana (cabazitaxel)
|
J9043
|
Alimta (pemetrexed)
|
J9305
|
Kadcyla (ado-trastuzumab emtansine)
|
J9354
|
Asparlas (calaspargase pegol-mknl)
|
J9118
|
Keytruda (pembrolizumab)
|
J9271
|
Avastin (bevacizumab)
|
J9035
|
Kyprolis (carfilzomib)
|
J9047
|
Bendeka (bendamustine)
|
J9034
|
Lartruvo (olaratumab)
|
J9285
|
Besponsa (inotuzumab ozogamicin)
|
J9229
|
Lumoxiti (moxetumomab pasudotox-tdfk)
|
J9313
|
Blincyto (blinatumomab)
|
J9039
|
Mylotarg (gemtuzumab ozogamicin)
|
J9203
|
Cyramza (ramucirumab)
|
J9308
|
Neupogen (filgrastim)
|
J1442
|
Darzalex (daratumumab)
|
J9145
|
Oncaspar (pegaspargase)
|
J9266
|
Doxorubicin liposomal
|
Q2050
|
Opdivo (nivolumab)
|
J9299
|
Elzonris (tagraxofusp-erzs)
|
J9269
|
Padcev (enfortumab vedotin-ejfv)
|
J9177
|
Empliciti (elotuzumab)
|
J9176
|
Polivy (polatuzumab vedotin-piiq)
|
J9309
|
Enhertu (fam-trastuzumab deruxtecan-nxki)
|
J9358
|
Rituxan (rituximab)
|
J9312
|
Erbitux (cetuximab)
|
J9055
|
Sarclisa (isatuximab-irfc)
|
J9999
|
Erwinase (asparginase)
|
J9019
|
Sylvant (siltuximab)
|
J2860
|
Ethyol (amifostine)
|
J0207
|
Treanda (bendamustine)
|
J9033
|
Granix (tbo-filgrastim)
|
J1447
|
Vectibix (panitumumab)
|
J9303
|
Halaven (eribulin mesylate)
|
J9179
|
Yervoy (ipilimumab)
|
J9228
|
Herceptin (trastuzumab)
|
J9355
|
Zaltrap (ziv-aflibercept)
|
J9400
|
Imfinzi (durvalumab)
|
J9173
|
|
|
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Note: In some plans, dose reduction to nearest whole vial or waste reduction may be the term used in benefit plans, provider contracts or other materials instead of or in addition to dose reduction to nearest whole vial. In some plans, these terms may be used interchangeably. For simplicity, we have uses dose reduction (to nearest whole vial).
517400MUPENMUB On June 18, 2020, August 21, 2020, and November 20, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (Anthem). These policies were developed, revised or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
April 5, 2021
|
ING-CC-0183*
|
Sogroya (somapacitan-beco)
|
New
|
April 5, 2021
|
ING-CC-0148*
|
Agents for Hemophilia B
|
Revised
|
April 5, 2021
|
ING-CC-0149*
|
Select Clotting Agents for Bleeding Disorders
|
Revised
|
April 5, 2021
|
ING-CC-0065
|
Agents for Hemophilia A and von Willebrand Disease
|
Revised
|
April 5, 2021
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
April 5, 2021
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
Revised
|
April 5, 2021
|
ING-CC-0121*
|
Gazyva (obinutuzumab)
|
Revised
|
April 5, 2021
|
ING-CC-0048 *
|
Spinraza (nusinersen)
|
Revised
|
April 5, 2021
|
ING-CC-0002*
|
Colony Stimulating Factor Agents
|
Revised
|
April 5, 2021
|
ING-CC-0034*
|
Hereditary Angioedema Agents
|
Revised
|
April 5, 2021
|
ING-CC-0041*
|
Complement Inhibitors
|
Revised
|
April 5, 2021
|
ING-CC-0071*
|
Entyvio (vedolizumab)
|
Revised
|
April 5, 2021
|
ING-CC-0064*
|
Interleukin-1 Inhibitors
|
Revised
|
April 5, 2021
|
ING-CC-0042*
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
April 5, 2021
|
ING-CC-0066*
|
Monoclonal Antibodies to Interleukin-6
|
Revised
|
April 5, 2021
|
ING-CC-0050*
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
April 5, 2021
|
ING-CC-0078*
|
Orencia (abatacept)
|
Revised
|
April 5, 2021
|
ING-CC-0063*
|
Stelara (ustekinumab)
|
Revised
|
April 5, 2021
|
ING-CC-0062*
|
Tumor Necrosis Factor Antagonists
|
Revised
|
April 5, 2021
|
ING-CC-0003*
|
Immunoglobulins
|
Revised
|
April 5, 2021
|
ING-CC-0039*
|
GamaSTAN [immune globulin (human)]
|
Revised
|
April 5, 2021
|
ING-CC-0053
|
Injectable Hydroxyprogesterone for Prevention of Preterm Birth
|
Revised
|
April 5, 2021
|
ING-CC-0073*
|
Alpha-1 Proteinase Inhibitor Therapy
|
Revised
|
April 5, 2021
|
ING-CC-0075
|
Rituximab Agents for Non-Oncologic Indications
|
Revised
|
April 5, 2021
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
April 5, 2021
|
ING-CC-0027*
|
Denosumab Agents
|
Revised
|
April 5, 2021
|
ING-CC-0019*
|
Zoledronic Acid Agents (Reclast, Zometa)
|
Revised
|
April 5, 2021
|
ING-CC-0011*
|
Ocrevus (ocrelizumab)
|
Revised
|
April 5, 2021
|
*ING-CC-0174*
|
Kesimpta (ofatumumab)
|
Revised
|
517460MUPENMUB On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (Anthem). These policies were developed, revised or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newsly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
04/15/2021
|
ING-CC-0185*
|
Oxlumo (lumasiran)
|
New
|
04/15/2021
|
ING-CC-0184*
|
Danyelza (naxitamab-gqgk)
|
New
|
04/15/2021
|
ING-CC-0154
|
Givlaari (givosiran)
|
Revised
|
04/15/2021
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
04/15/2021
|
ING-CC-0002
|
Colony Stimulating Factor Agents
|
Revised
|
04/15/2021
|
ING-CC-0032*
|
Botulinum Toxin
|
Revised
|
04/15/2021
|
ING-CC-0015
|
Infertility and HCG Agents
|
Revised
|
517445MUPENMUB |