 Provider News ColoradoJanuary 2024 Provider Newsletter Contents
COBCBS-CRCM-047200-23 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). When using or billing air ambulance services, please remember: - To facilitate timely and accurate claim processing of air ambulance services, include the facility’s record (emergency department record, or if an inpatient, the discharge or transfer summary) along with your run sheet. Providing this information will greatly facilitate timely review of medical necessity.
- Regarding the practice of using air ambulance services solely because use of ground transport would temporarily deplete local area Emergency Medical Services (EMS) availability, while EMS availability is always a local EMS concern, please understand that this reason alone does not meet medical necessity criteria for our members.
- Lastly, excess miles flown to keep a patient within the sending facility’s health system, when another closer capable receiving hospital has capacity, does not meet medical necessity criteria. Determination of medical necessity, including mode of transportation, is determined in accordance with Anthem’s clinical guidelines and medical necessity criteria. These determining guidelines include only approving the distance to the closest capable facility with capacity.
Taking the above into consideration will result in faster processing and lower denials of your air ambulance service claims. For your reference, see CG-ANC-04 Ambulance Services: Air and Water. If you have questions, contact your local provider relationship management representative. We look forward to working together to achieve improved outcomes. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047454-23-CPN47431 Effective January 1, 2024, Northrop Grumman Corporation will contract with Quantum Health to perform health care navigation and care coordination services for their active member population only. As part of this contract, Quantum Health will support member healthcare and benefit needs, including member and care provider services and medical utilization review and submission to Anthem. Northrup Grumman Corporation active members may be identified by the group number beginning with 174022 on the member ID card. A sample ID card is below. Anthem will remain responsible for claims adjudication and certain services as described below. Anthem will also remain the administrator of Behavioral Health Utilization Management, inclusive of retrospective reviews, and Case Management. Quantum Health is the point of contact for member and care provider inquiries. Quantum Health will be the point of contact for members and healthcare providers to verify: - Benefit coverage information.
- Eligibility inquiries.
- Prior-authorization submission and review (as stated above).
Anthem will remain the point of contact for care providers for the following:- Behavioral Health Utilization Management, inclusive of retrospective reviews and Case Management.
- Quantum Health will redirect care provider questions/inquiries to Anthem or local Blue for Medical and Behavioral Health Services for the following:
- Care provider contracting.
- Remittances.
- Fee schedule.
- Value Based Programs.
- Network status.
- Demographic information updates.
Sample Member ID cardBased on the information outlined above, there are changes in the Member Services and Provider Services/pre-certification phone numbers. These two new phone numbers are located on the back of the Medical Member ID card. 
If you have any questions, please contact your provider relationship management representative. We are committed to a future of shared success. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047992-23 Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed. Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. Online update options include: - Adding/changing an address location.
- Changing a name.
- Changing a phone/fax number.
- Provider leaving a group or a single location.
- Closing a practice location.
The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information helps us ensure your online provider directory information is current. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047108-23 According to ICD-10-CM guidelines for coding and reporting, it is inappropriate to bill certain diagnosis codes as a primary or first listed diagnosis. Instead, these codes should always be sequenced as a secondary or subsequent diagnosis. Effective for claims processed on or after April 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny: - Professional claims submitted on a CMS-1500 form that report inappropriate primary diagnosis codes as the only diagnosis on the claim or claim line; and facility claims submitted on a CMS-1450 form that report inappropriate primary diagnosis codes as the principal diagnosis or only code on the claim.
As provided by ICD-10-CM guidelines, inappropriate primary diagnosis codes include but are not limited to: - External Cause Codes of Morbidity (V, W, X, or Y codes [ICD-10-CM]) describes an environmental event causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. These codes are intended to be supplemental to the principal or primary diagnosis code indicating the nature of the condition. In addition, based on this guideline, a diagnosis code of external causes cannot be the only diagnosis on the claim.
- Manifestation Codes: Certain conditions contain both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD Manual coding guidelines have established a coding convention that requires the underlying condition to be sequenced first followed by the manifestation. According to the ICD Manual coding guidelines, the primary, first listed, or principal diagnosis cannot be a manifestation code. In addition, based on this guideline, a manifestation code cannot be the only diagnosis on the claim.
- Sequela Codes: a sequela (7th character "S") code cannot be listed as the primary, first listed, or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code. In addition, based on this guideline, a sequela (7th character "S") code cannot be the only diagnosis on a claim.
- Secondary Diagnosis: According to ICD guidelines, a secondary diagnosis code can only be used as a secondary diagnosis. Since these codes are only for use as supplemental codes, any procedure or service received with a secondary diagnosis code as the principal or primary diagnosis will be denied as incorrectly coded.
EOB Message: We denied this service since it was reported incorrectly. Per CMS (Federal) correct coding guidelines, specific Supplementary Classification ICD-10 codes cannot be used as the primary diagnosis or as the only diagnosis on the claim. Ex-Codes: 00V16 and v16 Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-035113-23-CPN34788 Routinely, the Centers for Medicare & Medicaid Services (CMS) issue revisions to the average sales price (ASP) fee schedules regarding drug pricing. To that end, CMS is supplying the first quarter fee schedule with an effective date of January 1, 2024. This will go into effect with Anthem on February 1, 2024. To view the ASP fee schedule, visit the ASP Pricing Files page on the CMS website. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-046389-23 As we communicated in October, November, and December 2023, Availity Essentials Provider Data Management (PDM) is the only intake application for care providers to submit demographic change requests, including submitting roster uploads. Availity Essentials PDM will replace all previous intake channels for demographic change requests and roster submissions as of January 1, 2024. Care providers should continue to use the Provider Enrollment application in Availity Essentials to submit requests to add new practitioners under existing groups that require credentialing. Training is availableAvaility Essentials PDM application specific training: - An Availity Essentials account is required for accessing these training options. If not registered yet, see information below for registration details. Note: You must log in to Availity Essentials first. Then, select the link:
- Learn about and attend one of our live webinars here.
- View the Availity Essentials PDM quick start guide here.
Roster Automation Template and Rules of Engagement specific training:- If you missed one of our trainings throughout November and December 2023, register and listen to a recording here.
Benefits to our care providers using Availity Essentials PDMThe benefits of the Availity Essentials PDM application include the following: - Ability to attest and manage current provider demographic information
- Provides consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
Choice and flexibility to select the option that works best for youRequest data updates via either one of the following options with Availity Essentials PDM: - Multi-payer platform option: Allows providers to make updates once and have that information sent to all participating health plans, submitting each change separately
- Roster upload option: Allows providers to submit multiple updates within one spreadsheet via the Upload Rosters feature:
- The Upload Roster feature is currently only available and shared with, Anthem.
Want to submit a roster using Availity Essentials PDM?Now you can. Roster Automation is the new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:* - Use the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement. Find it online here.
- This reference document is available to ensure error-free submissions, driving accurate and more timely updates through automation.
- More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide).
- Upload your completed roster via the Availity Essentials PDM application.
How to access the Availity Essentials PDM applicationLog on to Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts. 
Availity administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by your Availity administrator. To find your Availity administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by logging into Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY (800-282-4548). Exclusions:- Behavioral health providers assigned to Carelon Behavioral Health, Inc. will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
- Any specific state mandates or requirements for provider demographic updates
We are focused on reducing administrative burdens, so you can do what you do best – care for our members. * If any roster data updates require credentialing, your submission will be routed appropriately for further action. Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CRCM-045318-23-CPN45301 Now accepting Medicaid and Medicare member claimsAs a care provider taking advantage of digital requests for additional information (Digital RFAI), you know it is the most efficient way to send the required documentation to process your Commercial member claims. As of mid-November, you also can receive Digital RFAI notifications for your Medicaid and Medicare member claims. The process will not change for Medicaid and Medicare member claims. You will still follow the same fast and easy process for our Medicaid and Medicare member claims as you do for your commercial member claims. The only change is that your Medicaid and Medicare member claims will not pend. Medicaid and Medicare member claims will deny when additional documentation is needed to process the claim. Notifications will remain on your dashboard for up to 30 days as they do today. Submit the documentation at your convenience (most care providers submit documents within seven to 14 days). Your notifications will continue to arrive on your dashboard each morning, making it convenient to plan your work; no need to check your dashboard throughout the day. Learn more!In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration: Date | Time | | January 23, 2024 | 2:30 to 3:45 p.m. ET |
Availity administrators can use this link to register for live training or to view the training on demand. For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient: Date | Time | | January 23, 2024 | 2:30 to 3:30 p.m. ET |
Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training, or to view the live training on-demand. Contact Availity Customer Support at availity.com/Contact-Us or your provider relationship representative if you have any questions. Not a Digital RFAI care provider?If you’re not already using the Digital RFAI process and want to take advantage of faster claims processing, participation is easy. 1. | Registration | The organization’s Availity administrator will register for Medical Attachments, which enables care provider organizations to receive notices from the payer and submit requested documents digitally. | All billing NPIs/TINs must be registered. | 2. | User roles | The Availity administrator will be required to update or add new users with these specific role assignments through Availity: - Claims Status
- Medical Attachments
| Enable users to view the Availity Attachment Dashboard. | 3. | Ready to go! | After the registration and user roles are completed on Availity, the Digital RFAI process is ready. | Requests will automatically appear on the Attachments Dashboard each morning (when documents are needed). |
We are committed to finding solutions that help our care provider partners offer quality services to our members. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047947-23-CPN47121 Effective January 1, 2024, most specialty prescriptions will transfer to BioPlus, CarelonRx specialty pharmacy that services Anthem members. This migration is taking place in multiple waves throughout the next year. What happens next?- If you have patients affected by this pharmacy change, BioPlus will contact you to request new prescriptions, refills, or prior authorizations. You will also receive a letter from CarelonRx.
- Current specialty prescriptions with open refills will automatically transfer to BioPlus.
- Impacted patients will receive a letter and a phone call, explaining this transition.
- There is nothing you or your patients need to do except speak with BioPlus when they call.
What is the benefit to you and your patients?CarelonRx and BioPlus work together to deliver patients an unparalleled level of high-tech, high-touch service that focuses on their whole health. As a care provider, you will receive fast and easy benefit confirmation and prior authorizations for expedited time to therapy. BioPlus also offers comprehensive infusion services that include dedicated nurse concierges, patient advocates, and disease-specific education and clinical reminders. If you have any questions, please call your Anthem representative. We’re here to help. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047443-23-CPN47164 Note: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered Adopted for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are Adopted for those purposes. Refer to attachment to view full details Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-047109-23 ATTACHMENTS (available on web): Adopted Clinical Guidelines as of: January 1, 2024 (pdf - 1.08mb) Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-047104-23 ATTACHMENTS (available on web): Medical Policies and Clinical Guidelines notification letter (pdf - 0.47mb) On August 18, 2023, and August 30, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or 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 providers in 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.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | January 8, 2024 | *CC-0244 | Columvi (glofitamab-gxbm) | New | January 8, 2024 | *CC-0245 | Izervay (avacincaptad pegol) | New | January 8, 2024 | *CC-0246 | Rystiggo (rozanolixizumab-noli) | New | January 8, 2024 | *CC-0247 | Beyfortus (nirsevimab) | New | January 8, 2024 | CC-0001 | Erythropoiesis Stimulating Agents | Revised | January 8, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised | January 8, 2024 | CC-0104 | Levoleucovorin Agents | Revised | January 8, 2024 | CC-0100 | Romidepsin | Revised | January 8, 2024 | *CC-0182 | Iron Agents | Revised | January 8, 2024 | CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised | January 8, 2024 | CC-0176 | Beleodaq (belinostat) | Revised | January 8, 2024 | CC-0180 | Monjuvi (tafasitamab-cxix) | Revised | January 8, 2024 | CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised | January 8, 2024 | CC-0216 | Opdualag (nivolumab and relatlimab-rmbw) | Revised | January 8, 2024 | CC-0196 | Zynlonta (loncastuximab tesirine-lpyl) | Revised | January 8, 2024 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised | January 8, 2024 | CC-0203 | Ryplazim (plasminogen, human-tvmh) | Revised | January 8, 2024 | CC-0193 | Evkeeza (evinacumab) | Revised | January 8, 2024 | *CC-0034 | Hereditary Angioedema Agents | Revised | January 8, 2024 | *CC-0041 | Complement Inhibitors | Revised | January 8, 2024 | *CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised | January 8, 2024 | CC-0028 | Benlysta (belimumab) | Revised | January 8, 2024 | *CC-0243 | Vyjuvek (beremagene geperpavec) | Revised | January 8, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised | January 8, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised | January 8, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised | January 8, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised | January 8, 2024 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-044412-23-CPN44137 Effective for dates of service on and after April 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc. CPT® code | Description | 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and phenotype | 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure) | 0131U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure) | 0132U | Hereditary ovarian cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure) | 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) | 0135U | Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure) | 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite insta | 0287U | Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict | 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an | 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider | 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) | 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations | 0326U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number a | 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement | 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, | 0388U | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct | 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti | 0397U | Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, del | 0400U | Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie | 0401U | Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a |
As a reminder, ordering and servicing care providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access the Carelon Medical Benefits Management 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 Carelon Medical Benefits Management via Availity Essentials at Availity.com
For questions related to guidelines, please contact via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-041252-23-CPN40788 Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-043733-23-CPN41724 Effective April 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management, Inc. guidelines to perform medical necessity/clinical appropriateness reviews for requested cardiology interventions. Applicable CPT® codes lists are included in each guideline linked below: Preapproval requirements remain the same. The requested services received on or after April 1, 2024, will be reviewed with the new Clinical Criteria. As a reminder, ordering and servicing care providers may submit preapproval requests to Carelon Medical Benefits Management using the 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. For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. We are focused on reducing administrative burdens, so you can do what you do best – care for our members. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CR-043732-23-CPN41724 This article was updated on May 8, 2024. Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. RadiologyImaging of the heartCardiac CT
Cardiomyopathy: Added specificity to establish the basis for the suspicion of ARVD. This change aligns with Cardiac MRI guidelines.
Resting Transthoracic Echocardiography (TTE)
Evaluation of ventricular function: New indications for evaluation of patients on mavacamten for treatment of HOCM Imaging of the abdomen and pelvisBiliary tract dilatation or obstruction: Added indication for annual surveillance in Caroli disease/syndrome based on a 2022 guideline recommendation. Diffuse liver disease: Removed indication for LiverMultiScan in hemochromatosis as there is insufficient evidence that this provides an advantage over standard MRI for this condition Osteomyelitis: Added requirement for initial evaluation with radiographs in adult patients based on ACR appropriateness criteria. Septic arthritis: Added requirement for initial radiographs in adult patients based on ACR appropriateness criteria Pancreatic mass, indeterminate cystic (IPMN/IPMT): For enlarging lesions in patients age 80 or greater, increased surveillance frequency to annually and removed endpoint of 4 years. Pelvic floor disorders: Added indication for MRI (MR defecography preferred) in suspected pelvic organ prolapse based on ACR appropriateness criteria Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines Transplant-related imaging: Added indication for single CT abdomen or abdomen/pelvis prior to lung, kidney, or stem cell transplant to align with CT chest guidelines. Imaging of the brainMovement disorders (Adult only): Added indication for CT head for assessment of skull density prior to MRgFUS for essential tremor Trauma: Added a 3-6 week follow up study in patients age 6 or younger with stable or inconclusive exam, due to difficulty in accurately assessing for changes in neurologic status
Acoustic neuroma: Added long-term follow-up intervals based on specialty society guidelines Imaging of the chestPerioperative or periprocedural evaluation, not otherwise specified
Added indication for CT chest to be used for planning of biopsy or placement of fiducial markers using navigational bronchoscopy Imaging of the head and neckAcoustic neuroma: Added long-term follow-up intervals based on specialty society guidelines
Localized facial pain (including trigeminal neuralgia): Added MRI orbit/face/neck for this indication based on ACR criteria; some facilities use MRI face rather than brain for this condition Oncologic imagingCancer screeningBreast cancer screening:
Addition of high-risk genetic mutations (NCCN alignment citing absolute risk of 20% or greater) Lung cancer screening: Clarification of asbestos-related lung disease as risk factor independent of smoking, aligned with original intent. Pancreatic cancer screening:
Alignment with NCCN recommended parameters; changes are overall expansive, except for:
Older start age (from 45 to 50) for certain genes (ATM, BRCA1, BRCA2, MLH1, MSH2, MSH6, EPCAM, PALB2, TP53)
Family history alone (relative requirement) Breast cancer
CT chest, CT abdomen and pelvis: Added diagnostic workup allowance when metastatic disease is clinically suspected at presentation MRI breast: Addition/clarification of surveillance scenarios aligned with NCCN/ACR considerations
FDG-PET/CT: Added allowance for RT planning locoregional recurrence (e.g., confirmation of regional nodal involvement)
18F-fluoroestradiol (18F-FES) PET/CT: Added that it Is not indicated due to uncertain net benefit; low-level evidence, insufficient data on outcomes. Cervical cancer
Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
FDG-PET/CT: Update for follow-up of disease treated with either adjuvant RT or chemoradiation (NCCN alignment). Hepatocellular and biliary tract cancers
FDG-PET/CT: Removed routine preop PET/CT for biliary tract cancers (NCCN alignment) FDG-PET/CT: Added management allowance when standard imaging cannot be done or is nondiagnostic (NCCN "consider" for equivocal finding) Lung cancer – non-small cell
FDG-PET/CT: Added management allowance when recurrence demonstrated by surveillance imaging (NCCN alignment) Lung cancer – small cell
FDG-PET/CT: Clarification of initial staging allowance (NCCN alignment Lymphoma – Non-Hodgkin and Leukemia
FDG-PET/CT: NCCN alignment for interim restaging (allowed for DLBCL stage I-IV with or without bulky disease) Melanoma
Added surveillance option with MRI abdomen for liver metastases. Prostate cancer
18F Fluciclovine PET/CT or 11C Choline PET/CT, 68GaProstate-specific membrane antigen (PSMA) PET/CT or 18F-DCFPyL (piflufolastat or Pylarify) PET/CT
Addition of diagnostic workup/initial staging indication.
Specification of androgen-receptor pathway inhibitor treatment in alignment with Carelon Medical Benefits Management Inc. Radiation Oncology Guidelines. Sarcomas of bone/soft tissue
FDG-PET/CT: Added allowance when standard imaging nondiagnostic or contraindicated (bone/soft tissue sarcoma). Radiation oncologyIMRT for colon cancer
New indication for adjuvant treatment of locally advanced adenocarcinoma of the cecum. SBRT for hepatocellular carcinoma
Modify eligibility criteria to match clinical trial RTOG 1112 EBRT/IMRT for prostate cancer
Adjust for 2 Gy fractions. The total allowed dosage is the same with each fraction is a little larger (now 2 Gy) and lower number of fractions. Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines Musculoskeletal: interventional pain managementEpidural injection procedures and diagnostic selective nerve root blocks
Added osteoporotic fracture as a contraindication because of increased risk of fracture and confounding source of pain. Therapeutic intraarticular facet joint injections
Added exclusions for use of endoscopic neurolysis or rhizotomy, Diagnostic medial branch blocks, therapeutic intraarticular facet joint injections, and radiofrequency neurotomy when performed at C0-C1 or at C1-C2, and Platelet-rich plasma injections Spinal cord and dorsal root ganglion stimulators
Added indication of PDN for spinal cord stimulation with strict criteria. Added clarifications. Sacroiliac joint fusion
Revised exclusion to include procedures that use a transfixing device. Rehabilitative servicesPhysical therapy, occupational therapy, speech therapyAdjunctive & alternative treatments physical therapy
Added Fluidotherapy as an exclusion.
Removed the following services from the list of Exclusions: Active Therapeutic Movement®, Interactive metronome®, MEDEK (Dynamic Method of Kinetic Stimulation)®, Whole body advanced exercise, and Whole body vibration As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following: • Access Carelon Medical Benefits Management 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. For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CR-043709-23-CPN42002 Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-047190-23 ATTACHMENTS (available on web): Expansion of Carelon Medical Benefits Management programs (pdf - 0.82mb) As communicated in the November 2023, provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross and Blue Shield members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable. The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical, and Radiation Therapy programs. Refer
to attachment to view full details Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-045225-23-CPN44885 ATTACHMENTS (available on web): Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024 (pdf - 0.73mb) Welcome to our monthly provider newsletter: stay informed We are thrilled to include our dental providers in our monthly provider newsletter. In these monthly publications, we will communicate important updates, informative educational articles, and more. New articles are published on the first business day of each month, so be sure to bookmark this location and visit this page regularly for updates. Our dedicated team is committed to making important information easy for you to find, so that you can continue providing excellent care to your patients. Consolidated Appropriations Act provider directory federal mandate – provider directories effective January 1, 2022 As required by the Consolidated Appropriations Act (CAA) and several state laws, we must ensure our provider directories are accurate. Your patients, our members, need the most up-to-date information to reach you. Please keep us informed of any changes impacting you or your office, especially those changes impacting the directory. We will reach out to our contracted providers as required by Federal and State laws to verify contact information. As a contracted provider, you must respond to the notification by providing updated contact information. We appreciate your due diligence in keeping us informed of any changes impacting you or your office. Working together, we ensure your patients, our members, can reach you quickly while we meet our compliance obligations. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-DEN-047183-23-CPN47030 Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-047317-23 ATTACHMENTS (available on web): Prior authorization updates for specialty pharmacy (pdf - 0.08mb) We’re committed to ensuring every eligible member receives an Annual Planned Visit (APV) this year and appreciate your help to make this happen. Tips to help your practice boost APV rates early in the year:- Members do not need to wait a full calendar year between wellness visits. Coverage resets on January 1 and we encourage all eligible members to schedule wellness visits with their care provider.
- Outreach to members within their first year of Medicare to schedule their Welcome to Medicare Exam (or Initial preventive physical exam, IPPE) and explain its importance.
- Know who your hard-to-engage members are and start contacting them earlier in the year.
- The Provider News Quality Management page is a great resource to learn more about optimizing your quality scores and staying up to date on our latest communications.
- While everyone is eligible for an annual wellness visit, some of the topics discussed during the visit may require additional follow-up to close a care gap. Be aware of scheduling lead times with other facilities for certain visit types, like mammograms, DEXA scans, and colonoscopies. Try to prioritize these patients who need these services for wellness visits.
- The AWV is a hands-off appointment that can be conducted via telehealth. This may be a great option for patients with mobility or access issues or compromised immune systems. See our guide for how to facilitate these exams via telehealth here.
APV coding guidelines:*Verify member’s benefits and eligibility prior to scheduling
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-040774-23-CPN40559 CORRECTION: The BPD article was originally published stating the Compliance is greater than 139/89. The statement has been corrected to Compliance is less than 140/90. HEDIS® 2023 documentation for Blood Pressure Control for Patients With Diabetes (BPD)Measure descriptionThe percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg) during the measurement year. What we are looking for in provider records: - Last BP documented in 2023 regardless of reading
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Take a second BP at the end of the office visit if initial BP was > 140/90 and document new BP.
- Consider taking BP at every visit.
- Remind medical staff not to round results. Results must be precise (such as, 139/89).
- Compliance is less than 140/90.
- Counsel on healthy habits for managing high blood pressure.
- Encourage antihypertensive and other medication adherence.
- Member reported BPs during a telehealth visit are acceptable and should be documented in the members health record
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS 2023 documentation for Hemoglobin A1c Control for Patients With Diabetes (HBD) Measure descriptionThe percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) was at the following levels during the measurement year: - HbA1c control (< 8.0%)
- HbA1c poor control (> 9.0%)
What we are looking for in provider records: - Last HbA1c documented in 2023 regardless of result
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Counsel on healthy habits for managing diabetes.
- If appropriate, set an HbA1c goal of less than 7%.
- Encourage timely HbA1c testing.
- Encourage medication adherence.
- Encourage continuous glucose monitoring.
- In progress notes when documenting HbA1c value include date the test was performed.
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS 2023 documentation for Eye Exam for Patients With Diabetes (EED)Measure description The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) who had a retinal eye exam. What we are looking for in provider records: - Evidence of a retinal eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or year prior with results
- Bilateral eye enucleation any time during the member’s history
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Refer patients to an optometrist or ophthalmologist for a dilated or retinal eye exam annually.
- Fundus/retinal photography is considered imaging and is eligible for use, must be dated and interpreted by an eye care professional.
- Counsel on healthy habits for managing diabetes.
- In progress notes when documenting a retinal eye exam include the name of eye care provider or optometrist/ophthalmologist credentials, date performed, and result.
- Encourage medication adherence.
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-041667-23-CPN41092 With the New Year, people often make resolutions or set goals for themselves. Let this be the year that you see all your patients for their annual preventive care visit. As you know, annual visits are mutually beneficial to both you and your patients. These visits help establish a strong provider-patient relationship, which is essential in achieving the best healthcare outcomes. Establishing baseline measurements, knowing family history, and understanding unique risk factors and concerns can help you provide appropriate and culturally sensitive guidance on reducing risk for disease. Patients who report positive interactions with their healthcare providers demonstrate greater self-management and quality of life, as well as a reduction in emergency room visits and inpatient admissions. Start the new year on the right foot: - If you are seeing a patient for the first time, ask them to have their previous provider send their medical records.
- Begin reaching out to harder to engage patients early in the year.
- Reach out to patients at least [two months] prior to their birthday to schedule an appointment.
- Remind patients of their upcoming appointment via phone, text, and/or email as it approaches to avoid no shows.
- Remember to verify your patient’s benefits and eligibility prior to scheduling appointments.
- Screen for social needs that may be a barrier for care.
- If you need to refer a patient for a test or to a specialist, manage their expectations and follow-up with both the patient and provider.
Make sure to get the credit you deserve by reporting all services provided and use all appropriate billing codes: - The annual visit service is coded based on the patient’s age.
- Use CPT® Category II codes with your claims encounters to maximize HEDIS® data collection and reduce the burden of HEDIS medical record review. Go to the American Medical Association website at ama-assn.org for a complete list of CPT codes.
- If you are using an electronic medical record system, consider electronic data sharing with the health plan to capture all coded elements to facilitate HEDIS data collection and more accurate gap in care reports.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-045214-23-CPN44820 |