 Provider News ColoradoJune 2021 Anthem Provider News and Important Updates - ColoradoNationally, seven percent of all claims are denied because they weren’t filed within the timely filing limits. At Anthem Blue Cross and Blue Shield (Anthem), we want your claims to be received on time, so they get paid on time. One way to ensure your claim isn’t denied because it wasn’t received within timely filing limits is to follow-up with your clearinghouse on a regular basis.
When you send claims electronically through a clearinghouse, if errors are identified on the claims, they won’t get submitted for payment. Checking in regularly with your clearinghouse is key to identifying claims errors. This gives you the opportunity to correct claims quickly, avoiding delays in filing and running the risk of a claim denial because it wasn’t filed within the timely filing limit.
Have you confirmed the patient is an Anthem member?
Another reason claims are delayed is because the claim was filed with Anthem, but it should have been filed with another insurance company first. To make sure your claim is received on time, double check the member’s insurance information with each visit to your office confirming their primary insurance. To check the member’s eligibility or to get a digital copy of the member’s ID card, log onto Availity.com. From the Patient Registration tab use the Eligibility and Benefits Inquiry tool for a quick and easy search.
Checking your claims status.
It is easy to check your claim online to confirm we’ve received it. Log onto Availity.com and use the Claims & Payment tab for the Claims Status tool. You may also be able to check the claim to verify no adjustments are needed through the Claims Status Listing application located on the Payer Spaces home page.
The sooner you file the faster your claim is paid.
Filing your claim within the timely filing limits can eliminate claim denials. If your claim denies because it was filed late, Anthem will deny the claim as outlined in your contract with us. It is important to note that the member cannot be billed for denied claims that were not filed timely.
Use these helpful tips when filing your claims because Anthem understands that timely payments are as important as timely filing.
1182-0621-PN-COChances are that one out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.1 Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.2 For this reason, the National Committee for Quality Assurance (NCQA) recommends avoiding imaging for patients when there is no indication of an underlying condition. In a study published by the CDC, Early imaging for acute low back pain, the findings indicated not only was early imaging not associated with better outcomes, it also indicated that certain early imaging (MRI) was associate with an increased likelihood of disability and its duration.3
Watch this video to learn more
Take advantage of the Recommendation for Treating Acute Low Back Pain video located on the CDC website or use this link. The video also offers communications strategies to share with patients for effectively treating their low back pain.
HEDIS® Measure: Use of Imaging Studies for Low Back Pain (LBP)
Description: The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The higher compliance score indicates appropriate treatment of low back pain.
Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.
Coding Tips: This is a few of the approved codes for the diagnosis and services associated with the LBP measure. For a complete list, visit ncqa.org.
|
CPT
|
72010, 72020, 72052, 72100
|
Imaging study
|
|
ICD-10
|
M47.898
|
Other spondylosis, sacral and sacrococcygeal region
|
|
ICD-10
|
M48.08
|
Spinal stenosis, sacral and sacrococcygeal region
|
|
ICD-10
|
M53.2X8
|
Spinal instabilities, sacral and sacrococcygeal region
|
|
ICD-10
|
M54.40
|
Lumbago with sciatica, unspecified side
|
|
ICD-10
|
M51.26 – M51.27
|
Other intervertebral disc displacement, lumbar lumbosacral region
|
|
ICD-10
|
M54.30 – M54.32
|
Sciatica, unspecified, right side, left side
|
|
ICD-10
|
M51.16-M51.17
|
Intervertebral disc disorders with radiculopathy, lumbar region, lumbosacral region
|
|
ICD-10
|
M51.26-M51.27
|
Intervertebral disc displacement, lumbar region, lumbosacral region
|
|
ICD-10
|
M51.36-M51.37
|
Other intervertebral disc degeneration, lumbar region, lumbosacral region
|
|
ICD-10
|
M51.86-M51.87
|
Other intervertebral disc disorders, lumbar region, lumbosacral region
|
|
ICD-10
|
M99.53
|
Intervertebral disc stenosis of neural canal of lumbar region
|
|
ICD-10
|
S33.100A, S33.100D, S33.100S
|
Subluxation of unspecified lumbar vertebra; initial, subsequent, sequela encounter
|
|
ICD-10
|
S33.5XXA
|
Sprain of ligaments of lumbar spine; initial encounter
|
|
ICD-10
|
S33.6XXA
|
Sprain of sacroiliac joint; initial encounter
|
|
ICD-10
|
S33.8XXA
|
Sprain of other parts of lumbar spine and pelvis; initial encounter
|
|
ICD-10
|
S33.9XXA
|
Sprain of unspecified parts of lumbar spine and pelvis; initial encounter
|
|
ICD-10
|
S39.002A, S39.002D, S39.002S
|
Unspecified injury of muscle, fascia, and tendon of lower back; initial, subsequent, sequela encounter
|
|
ICD-10
|
S39.82XA, S39.82XD, S39.82XS
|
Other specified injuries of lower back; initial, subsequent, sequela encounter
|
1 https://www.cdc.gov/acute-pain/low-back-pain/index.html#:~:text=25%25%20of%20U.S.%20adults%20report,the%20most%20common%20pain%20reported.
2 https://abcnews.go.com/Health/CommonPainProblems/story?id=4047737#:~:text=Answer%3A%20Back%20pain%20usually %20goes,people%20recover%20faster%20than%20others
3 http://dx.doi.org/10.1097/BRS.0b013e318251887b
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
1180-0621-PN-CO
Easily update demographic changes and much more, by simply submitting your updates through Anthem Blue Cross and Blue Shield (Anthem) online Provider Maintenance Form. Online update options include: add an address location, name change, tax ID changes, provider leaving a group or a single location, phone/fax numbers, closing a practice location. Visit the Provider Maintenance Form landing page to review more.
Important information about updating your practice profile:
- Change request should be submitted using the online Provider Maintenance Form
- Submit the change request online. No need to print, complete and mail, fax or email demographic updates
- You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
- For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting
You can check your directory listing on the Anthem “Find Care”. The Find Care tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access Find Care. Go to anthem.com, and select Providers. Under Provider Resources, choose Find Care. Select Colorado as Your State. You can log in as a guest to view how you and your practice are being displayed.
1187-0621-PN-CO Our “Working with Anthem” webinars are focused on one topic each session and designed to help our providers and their staff learn how to use the tools currently available to improve operational efficiency when working with Anthem Blue Cross and Blue Shield (Anthem).
2021 Subject Specific Webinars
|
Topic:
|
Provider orientation for physical health and behavioral health providers
|
|
Date/Time:
|
Tuesday, June 29, 2021 from 12:00-1:00pm MT
|
|
Description:
|
This webinar is designed to introduce a number of self-service tools and valuable information about Anthem Blue Cross and Blue Shield to our Providers/Facilities and their office/billing staff for both Physical Health and Behavioral Health provider types.
Our agenda will include:
▪ Anthem Overview, including contact information and resources
▪ Before rendering service - what to do
▪ Claims Support
▪ Online Tools and Resources
Whether you are a new provider, have had a change in staff, or just need a refresher, join us for a general overview and onboarding. You will receive an 'Anthem 101' course to get you up to speed and up-to-date.
|
|
Registration link:
|
https://anthem.webex.com/anthem/onstage/g.php?PRID=b6a696587e498199466cadc7231c908d
|
Webinars are offered using Cisco WebEx. There is no cost to attend. Access to the internet, an email address and telephone is all that's needed. Attendance is limited, so please register today.
Watch for additional topics and dates in future issues of our monthly provider newsletter throughout the year. We also will continue to offer our Fall Provider Seminars which will continue to cover a variety of topics in face-to-face and webinar options.
Recorded sessions:
Most sessions are recorded, and playback versions are available on our Registration Page. The top portion of the page will show “Upcoming Events” and the bottom portion will show “Event Recordings”.
Note: Event Recordings will require a password. Please register for the event, even if you are unable to attend, to ensure you will be notified of the Event Recording and password once it is available.
1191-0621-PN-CO Are you aware that you have two self-service learning centers where you can find training and educational materials that will help you learn about the transactions and tools you have access to on the Availity Portal?
- Availity Learning Center: Your resource for information related to multi-payer tools and transactions.
- Custom Learning Center:Your resource for information related to Anthem tools that are accessed through the Availity Portal.
Availity Learning Center
Dive into the Availity Learning Center for training materials related to multi-payer functionality. Availity works with many payers to give you the most consistent experience available. For learning opportunities on basic capabilities that you access on behalf of multiple payers, the Availity Learning Center is your go-to source.
- From the secure Availity Portal home page select Help & Training > Get Trained to open the Learning Center catalog.
- Once you open the Availity Learning Center, you can enroll for new administrator and new user onboarding modules, other topic specific courses, and live webinars.
Custom Learning Center
Explore {Anthem’s} Custom Learning Center application on Payer Spaces to increase your understanding of how Anthem’s self-service digital tools function. The Custom Learning Center opens on the Catalog page where you will find videos and courses. Select Resources from the upper left corner of Custom Learning Center to access reference guides.
Use these self-service learning options to help you get up to speed quickly on Availity transactions and Anthem digital tools.
1154-0621-PN-CO Availity offers digital solutions that can assist your organization in many ways by visiting the Availity Support Community.
Below are the different ways you can obtain support:
- Watch Demos
- Troubleshooting
- FAQs
- Support Requests
- Network Outages
- Release Notes
Log into Availity > Select Help & Training > Availity Support > Select the Organization, Continue and you will reach the Availity Support Community.
1159-0621-PN-CO A new copy feature that will significantly speed up your authorization workflow is now available on Interactive Care Reviewer (ICR). Submit multiple requests in a fraction of the time it takes to create an entire case. You can choose to create a duplicate case or select specific elements of a case to copy for a different patient*. The copy feature will be particularly useful for facility staff requesting multiple authorizations for inpatient emergent / urgent admissions and providers who request multiple authorizations for the same services.
You have two options for copying a submitted case:
1. Immediately copy a case you just submitted from the ICR dashboard.
Select from the blue bar message located at the top of the dashboard.
2. Copy a case that has been submitted within 45 days from the ICR Case Overview Select the Copy Case button.
The Case Type, Request Type, Place and Type of Service is duplicated onto the new case. You will be given the option to select the following case details to copy:
- Diagnosis Code and Procedure Code
- Inpatient length of stay
- Requesting provider and contact information
- Servicing facility
- Inpatient length of stay
- Servicing provider
Simply key in the patient details* and add the clinical details to complete the new case.
*Please note: To duplicate the authorization request, the new patient needs to be enrolled in the same state and health plan as the patient’s case that is being copied. Federal Employee Program (FEP) requests can be duplicated for any state.
Want to learn more about the new ICR copy feature?
Attend our monthly live webinar sessions: Introduction to Interactive Care Reviewer Register here
Or, view and download an illustrated job aid – Interactive Care Reviewer Copy Feature.
Find the job aid on the Custom Learning Center: From Availity’s home page select Payer Spaces | Anthem tile | Custom Learning Center | Resources. To narrow the results, apply the Interactive Care Reviewer filter.
1185-0621-PN-CO Experience the future and be a part of Anthem Blue Cross and Blue Shield (Anthem) digital-first initiative by submitting your corrected claims using the Availity Portal or through Electronic Data Interchange (EDI).
The corrected claims process begins when a claim has already been adjudicated. Multiple types of errors that occur can typically be corrected quickly with the options below. As a reminder, the corrected claim must be received within the timely filing.
Availity Portal Corrected Claim Submission
You can recreate a claim and submit it as a replacement or cancellation (void) of the original claim, if the Anthem has already accepted the original claim for processing.
Follow these steps:
- In the Availity Portal menu, select Claims & Payments, and then select ProfessionalClaim or Facility Claim, depending on which type of claim you want to correct.
- Enter the claim information, and set the billing frequency and payer control number as follows:
- Replacement of Prior Claim or Void/Cancel of Prior Claim
- Billing Frequency(or Frequency Type) field, in the Claim Information section (for professional and facility claims) or Ancillary Claim/Treatment Information section (for dental claims).
- Set the Payer Control Number (ICN / DCN)(or Payer Claim Control Number) field to the claim number assigned to the claim by the Anthem. You can obtain this number from the 835 ERA or Remittance Inquiry on Payer Spaces.
- Submit the claim.
EDI Corrected Claim Submission
Corrected claims submitted electronically must also have the applicable frequency code.
Frequency Code: Indicates the claim is a correction of a previously submitted and adjudicated claim. Providers should use one of the following:
For corrected professional (837P) claims use one the following frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
- 7 – Replacement of Prior Claim\Corrected Claim
- 8 – Void/Cancel Prior Claim
For corrected institutional (837I) use Bill Type Frequency Codes to indicate a correction was made to a previously submitted and adjudicated claim:
- 0XX7 — Replacement of Prior Claim
- 0XX8 — Void/Cancel Prior Claim
Please confirm with your practice management software vendor, as well as your billing service or clearinghouse for full details with information for submitting correct claims.
We encourage you and your staff to utilize the digital methods available to submit corrected claims to save costs in mailing, paper, and your valuable time.
1177-0621-PN-CO Beginning with claims processed on or after June 1, 2021, Anthem Blue Cross and Blue Shield will enhance its claims editing systems to include an automated front end adjudication of claim edits.
1178-0621-PN-CO Healthcare providers are often seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.
Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:
- Address disparities for vaccine-preventable diseases
- Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine communications, providing vaccine education, and improving vaccine management and administration in your office;
- Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines; and
- Connect with your state immunization program, local immunization coalition or other vaccine advocates in your community to collaborate.
Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.
Let's Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.
1151-0621-PN-CO
Effective July 19, 2021, Anthem Blue Cross and Blue Shield (Anthem) and AIM Specialty Health® (AIM), a separate company, will launch a new Back Pain Management Program for Anthem fully-insured members. AIM works with leading insurers to help improve health care quality and manage costs for today’s most complex and prevalent tests and treatments, and to help promote care that is appropriate, safe and affordable. In pursuit of that commitment, we have created a new Back Pain Management program to educate and support members as they navigate through their back pain journey to help reduce risk of chronicity and minimize recurrences and complications.
The program will use predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.
Our targeting management process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors
- Risk stratification to help ensure the appropriate level of support is provided
- Targeted outreach to members through our digital engagement platform, email and telephone
- Customized education and support of provider treatments based on member’s specific needs
- Education and support of services such as behavioral health as appropriate
Members included in the new program
All fully-insured members currently participating in AIM and Anthem programs in Anthem are included. The following members are excluded: self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR, and the Federal Employee Program® (FEP®).
The AIM Back Pain Program microsite provides access to helpful information and tools such as program information and FAQs.
AIM Back Pain Program informational webinars
Anthem invites you to take advantage of a free informational webinar that will introduce you to the program. Go to the AIM Back Pain Program microsite to register for an upcoming webinar.
We value your participation in our network and look forward to working with you to help improve the health of our members.
1175-0621-PN-CO Osteoporosis affects more than 50 million Americans. Treatment options are better and bone fractures are more preventable the sooner it is detected. Does your patient meet the criteria for a DEXA bone scan? Initial or repeat bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions.
To assist providers in administrative requirements for bone mineral density (BMD) studies, the Federal Employee Program (FEP®) medical policy and utilization guidelines can be found on fepblue.org. The medical policy is titled, Medical Policy MPM 6.01.01, Bone Mineral Density Studies. Below is an outline of this policy.
Policy Statement:
An initial measurement of central (hip/spine) BMD using dual x-ray absorptiometry (DXA) may be considered medically necessary to assess future fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis.
BMD testing may be indicated under the following conditions:
- Women age 65 and older, independent of other risk factors
- Men age 70 and older, independent of other risk factors
- Younger postmenopausal women with an elevated risk factor assessment (see policy guidelines)
- Men age 50 to 70 with an elevated risk factor assessment (see policy guidelines)
- Adults with a pathologic condition associated with low bone mass or increased bone loss
- Adults taking a medication associated with increased bone loss
Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry for individuals who previously tested normal may be considered medically necessary at an interval not more frequent than every 3 to 5 years; the interval depends on an updated patient fracture risk assessment.
Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-2 years as follows:
- Individuals with a baseline evaluation of osteopenia (BMD T- score - 1.0 to -2.5)
- Adults with a pathologic condition associated with low bone mass or increased bone loss
- Adults taking a medication associated with increased bone loss
Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-3 years in individuals who are receiving pharmacologic treatment for osteoporosis when the information will affect treatment decisions (continuation, change in drug therapy, cessation or resumption of drug therapy).
Peripheral (lower arm, wrist, finger or heel) BMD testing may be considered medically necessary when conventional central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism, where peripheral DXA at the forearm (i.e., radius) is essential for evaluation.
Important reminders:
- Dual x-ray absorptiometry of peripheral sites is considered investigational except as noted above.
- BMD measurement using ultrasound densitometry is considered not medically necessary.
- BMD measurement using quantitative computed tomography is considered investigational.
If you have any questions about Federal Employee benefits or medical policy information, please contact Customer Service at 1-800-852-5957.
1176-0621-PN-CO
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.
1157-0621-PN-CO Effective September 1, 2021, Anthem Blue Cross and Blue Shield will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.
Goal length of stay (GLOS) for inpatient and surgical care (ISC)
|
Guideline
|
MCG Code
|
24th Edition GLOS
|
25th Edition GLOS
|
|
Aortic Coarctation, Angioplasty
|
S-152
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Cardiac Septal Defect: Atrial, Transcatheter Closure
|
W0016
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Esophageal Diverticulectomy, Endoscopic
|
S-445
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Gastrectomy, Partial - Billroth I or II
|
S-510
|
4 or 6 days postoperative
|
5 days postoperative
|
|
Hernia Repair (Non-Hiatal)
|
S-1305
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Pancreatectomy
|
S-1200
|
5 or 7 days postoperative
|
6 days postoperative
|
|
Pyloroplasty and Vagotomy
|
S-990
|
4 or 6 days postoperative
|
4 days postoperative
|
|
Cervical Laminectomy
|
W0097
|
2 days postoperative
|
Ambulatory or 2 days postoperative
|
|
Lumbar Diskectomy, Foraminotomy, or Laminotomy
|
W0091
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Removal of Posterior Spinal Instrumentation
|
S-530
|
1 day postoperative
|
Ambulatory or 1 day postoperative
|
|
Shoulder Hemiarthroplasty
|
W0138
|
1 day postoperative
|
Ambulatory or 1 day postoperative
|
|
Spine, Scoliosis, Posterior Instrumentation, Pediatric
|
W0156
|
4 days postoperative
|
3 days postoperative
|
|
Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent
|
S-190
|
5 or 6 days postoperative
|
5 days postoperative
|
|
Prostatectomy, Transurethral Resection (TURP)
|
S-970
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Urethroplasty
|
S-1172
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)
|
Body System
|
Guideline Title
|
MCG - Code
|
|
Withdrawal Management
|
Withdrawal Management, Adult: Inpatient Care
|
B-031-IP
|
|
Withdrawal Management
|
Withdrawal Management, Adult: Intensive Outpatient Program
|
B-031-IOP
|
|
Withdrawal Management
|
Withdrawal Management, Adult: Outpatient Care
|
B-031-AOP
|
|
Withdrawal Management
|
Withdrawal Management, Adult: Partial Hospital Program
|
B-031-PHP
|
|
Withdrawal Management
|
Withdrawal Management, Adult: Residential Care
|
B-031-RES
|
|
Cardiology
|
Hypertension
|
M-5197
|
|
Cardiology
|
Peripheral Vascular Disease (PVD)
|
M-7087
|
|
Nephrology
|
Rhabdomyolysis
|
M-7095
|
|
Nephrology
|
Encephalopathy
|
M-7100
|
|
Thoracic Surgery
|
Rib Fracture
|
M-5545
|
Customizations to MCG care guidelines 25th edition
Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented:
- Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:
- Need for acute TMS treatment, up to six weeks
- Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
- Continuation of acute treatment, up to six months
- TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
- Maintenance TMS treatment
- Continuation of acute TMS treatment for longer than six months
- TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.
To view a detailed summary of customizations, visit this link, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.
For questions, please contact the provider services at the number on the back of the member’s ID card.
* MCG Health is an independent company providing care guidelines on behalf of Anthem Blue Cross and Blue Shield.
517907MUPENMUB
The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines/search.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *CG-LAB-17 - Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
- Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
- *ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
- Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary
- *CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
- Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
- *CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor [GM-CSF]) as not medically necessary for all liver-related indications
- *CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
- Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
- Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
- Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications
- CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
- A new Clinical Guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
- CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions
- A new Clinical Guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
- CG-SURG-110 - Lung Volume Reduction Surgery
- A new Clinical Guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021
AIM Specialty Health®* Clinical Appropriateness Guideline updates. To view AIM guidelines, visit the AIM Specialty Health page.
- The Small Joint Surgery Guideline has been revised and will be effective on March 14, 2021.
- The following guidelines have been revised and will be effective on June 4, 2021:
- * Imaging of the Spine
- * Imaging of the Extremities
- * Vascular Imaging
- * Joint Surgery
- * Spine Surgery
Medical Policies
On February 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect June 4, 2021.
|
Publish date
|
Medical Policy number
|
Medical Policy title
|
New or revised
|
|
4/7/2021
|
*ANC.00008
|
Cosmetic and Reconstructive Services of the Head and Neck
|
Revised
|
|
2/18/2021
|
SURG.00121
|
Transcatheter Heart Valve Procedures
|
Revised
|
|
2/18/2021
|
SURG.00145
|
Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
|
Revised
|
Clinical UM Guidelines
On February 11, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on February 25, 2021. These guidelines take effect June 4, 2021.
|
Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or revised
|
|
4/7/2021
|
*CG-LAB-17
|
Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
|
New
|
|
2/18/2021
|
CG-GENE-21
|
Cell-Free Fetal DNA-Based Prenatal Testing
|
Revised
|
|
4/7/2021
|
CG-MED-26
|
Neonatal Levels of Care
|
Revised
|
|
2/18/2021
|
CG-MED-87
|
Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
|
Revised
|
|
4/7/2021
|
*CG-OR-PR-04
|
Cranial Remodeling Bands and Helmets (Cranial Orthotics)
|
Revised
|
|
2/18/2021
|
CG-SURG-55
|
Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
|
Revised
|
|
4/7/2021
|
CG-SURG-71
|
Reduction Mammaplasty
|
Revised
|
|
4/7/2021
|
*CG-SURG-78
|
Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
|
Revised
|
|
4/7/2021
|
*CG-SURG-82
|
Bone-Anchored and Bone Conduction Hearing Aids
|
Revised
|
|
4/7/2021
|
CG-SURG-97
|
Cardioverter Defibrillators
|
Revised
|
518566MUENMUB The Group Retiree Medicare Advantage membership is experiencing a high volume of enrollment, and as we continue to grow, we wanted to send these reminders for our PPO plans for Anthem Blue Cross and Blue Shield (Anthem). Group Retiree Medicare Advantage memberships may include the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare and accepts the member’s PPO plan. These PPO plans also offer benefits that original Medicare doesn’t cover, including an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online* and SilverSneakers®.*
If you are already part of our Medicare Advantage PPO network, thank you. The attached FAQ will be helpful as you grow your practice and serve members who may be new to our Group Retiree PPO plans. Please read the entire FAQ for more information through the link below.
https://files.providernews.anthem.com/1180/FAQ_MARetireePPOABCCRNU-0174-21.pdf
518502MUPENMUB |