Anthem Blue Cross and Blue Shield (Anthem) is committed to making healthcare simpler and reducing health disparities. We believe that open discussions about the disability experience for people of and reducing implicit bias, is critical to improving the health and wellbeing of all Americans and the communities in which we live and serve.

 

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race on our health and wellbeing. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.    

 

Wednesday, June 22, 2022

4:00 p.m. to 5:30 p.m. ET (2:00 p.m. to 3:30 p.m. MT)

 

Please register for this event by June 22, 2022

Register today!

 

*Motivo is an independent company providing a virtual forum on behalf of Anthem Blue Cross and Blue Shield.

COBCBS-COMM-000584-22

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Please review your demographic information in our online provider directories to ensure members and fellow providers can reach you.

 

Submit your updates by using our online Provider Maintenance Form. Update options include:

• add/change an address location
• name change
• tax ID changes
• provider leaving a group or a single location
• phone/fax number changes
• closing a practice location

 

You will receive an email to acknowledge your submitted Provider Maintenance Form. Visit the Provider Maintenance Form landing page for complete instructions.

 

Thank you for doing your part to help keep our online provider directories up to date.

2681-0622-PN-CO

The Escalation Contact List has been updated and is available online. Please go to anthem.com.  Select Providers.  Under the Communications heading, select Contact Us.  Choose Colorado, then select Escalation Contact List.

2777-0622-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).

2022 Subject Specific Webinars – June schedule

 

Topic:	Availity Attachments Tool
Date/Time:	Tuesday, June 28, 2022, from 12:00-1:00pm MT
Description:	Learn how to submit attachments through Availity.com, and the best way to response to requests for additional information.
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.

2774-0622-PN-CO

One in every 10 Americans have diabetes, but one in every five don’t know they have it. This makes annual testing important to those who have symptoms. For those patients who are diagnosed, testing is vitally important to reducing serious health complications and the costs associated with them. It isn’t always easy to help patients understand the need for annual testing. The Centers for Disease Control and Prevention has resources you can use in your practice to educate, inform, and hopefully motivate your patients. Visit their website cdc.gov and use their Health Care Providers section to access patient education programs, prevention toolkits and more.

Measure up

 

Comprehensive Diabetes Care (CDC): This HEDIS® measure evaluates Anthem Blue Cross and Blue Shield members aged 18 to 75 years with type 1 or type 2 diabetes. Each year, members with type 1 or type 2 diabetes should have:

• Hemoglobin A1c (HbA1c) testing - HbA1c control (< 8%)
• Eye exam (retinal) performed
• Evaluation for kidney disease
• BP control (< 140/90 mm Hg)

 

Code type	Description	Code
ICD-10	Type 1 diabetes mellitus without complications	E10.9
ICD-10	Type 2 diabetes mellitus without complications	E11.9
ICD-10	Other specified diabetes mellitus without complications	E13.9

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

2765-0622-PN-CO

Beginning in June 2022, Anthem Blue Cross and Blue Shield (Anthem) will implement new processes for providers to validate the information we have in our online provider directories.

 

Individual providers

Anthem is partnering with CAQH to assist us in validation for individual providers. Providers will receive communications from CAQH asking them to register for CAQH ProView®, the online provider data-collection service, where providers can review and verify their information, as well as provide updates that may be needed.

 

Facilities and groups

Anthem is also partnering with First Source to assist us in validating information for facilities and groups. A file will be sent to providers with the information we have in our systems. We are asking that providers review this file, validate correct information and provide updates as needed.

 

If you have questions, please contact Provider Services.

2781-0622-PN-CO

In its efforts to improve the health of humanity, Anthem Blue Cross and Blue Shield (Anthem) has made a long-term commitment to reducing morbidity and mortality associated with substance use disorder. In recent years, with a focus on primary and secondary prevention, we’ve seen significant reductions in the use of inappropriate opioid prescriptions for acute and chronic pain as well as the promotion of and increased use of safe alternatives for pain management. Similarly, Anthem has been a leader in increasing access to evidence-based treatment for substance use disorders including medication for addiction treatment (MAT).

 

Unfortunately, the COVID-19 pandemic has hindered the nation’s progress as evidenced by a 30% rise in deaths from overdose that the nation has experienced with the majority being from opioids (CDC). The impact on overdose rates from the pandemic requires that we also increase our efforts at preventing deaths from opioid overdose. Specifically, there is a need/opportunity to work collaboratively with our partners in the community to increase access to the opioid overdose reversal drug naloxone (aka “Narcan”). Anthem’s internal claims data from the second quarter of 2021 shows that approximately 20% of members experiencing a non-fatal opioid overdose are starting and continuing with medication for opioid use disorder (MOUD) which can include buprenorphine, methadone, or naltrexone. However, only 7% of these members have evidence of filling a prescription for naloxone. These rates have improved from a 2015 baseline of approximately 1%, but we have significant room for improvement.

 

What can we do to address this?

First, be an advocate for destigmatizing substance use disorders by supporting efforts to improve access to MOUD and harm reduction strategies including the use naloxone. We can learn more at www.Shatterproof.org, which is an organization that Anthem has historically supported.

                                                                           

Second, educate your patients about substance use disorders including how to spot them in a loved one, and how to support them when considering change. Visit https://www.samhsa.gov/find-help/recovery for more information.

 

Third, learn more about the life saving opioid overdose reversal drug naloxone including how to obtain it, and how to administer it. See www.getnaloxonenow.org for more information.  

2284-0622-PN-CO

Please continue to check for important Medicare Advantage updates at https://www.anthem.com/ca/provider/medicare-advantage/ for the latest Medicare Advantage information, including:

 

• Updates to AIM Specialty Health Sleep Disorder Management Clinical Appropriateness Guidelines
• New specialty pharmacy medical step therapy requirements
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• Updates to AIM Specialty Health Musculoskeletal Clinical Appropriateness Guidelines

Evaluation and management services for COVID testing — professional

Effective with dates of service on or after September 1, 2022, Anthem Blue Cross and Blue Shield (Anthem) will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT^® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.

 

Prior to payment, Anthem will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Anthem will reimburse using CPT code 99211.

 

Professional providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.

 

If you have questions on this program, contact your Provider Experience representative.

ABSCRNU-0336-22

Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health_®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by Guideline

Imaging of the spine

• Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs

 

Imaging of the extremities

• Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture
• Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
• Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
• Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty

 

Vascular imaging

• Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios
• Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines
• Chronic stroke/TIA – New indication; modality approach by circulation presentation
• Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
• Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
• Stenosis or occlusion, extracranial carotid arteries – Post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
• Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
• Upper or lower extremity peripheral arterial disease (PAD):
• Suspected PAD without physiologic testing (including exercise testing) not indicated
• New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal_℠ directly at https://www.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 AIM via the Availity Portal* at https://www.availity.com  
• Call the AIM Contact Center toll-free number Monday through Friday from 7 a.m. to 7 p.m. CT:
• Colorado: 833-342-1256

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

ABSCRNU-0327-22

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 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.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• *CG-LAB-20 — Thyroid Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
• *CG-LAB-21 — Serum Iron Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
• *LAB.00043 — Immune Biomarker Tests for Cancer:
• Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
• Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
• The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
• Endometrial receptivity analysis
• Sperm-capacitation test
• Sperm deoxyribonucleic acid (DNA) fragmentation test
• Sperm penetration assay
• Uterine natural killer (uNK) cells test
• *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
• Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
• *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
• Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
• *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
• Revised Position Statement to include the prevention of lymphedema.
• *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
• The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
• *TRANS.00038 — Thymus Tissue Transplantation:
• Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.

 

Medical Policies

On February 17, 2022, 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, 2022.

 

Publish date	Medical Policy number	Medical Policy title	New or revised
04/13/2022	*LAB.00043	Immune Biomarker Tests for Cancer	New
04/13/2022	*LAB.00044	Saliva-based Testing to Determine Drug-Metabolizer Status	New
04/13/2022	*LAB.00045	Selected Tests for the Evaluation and Management of Infertility	New
04/13/2022	*LAB.00046	Testing for Biochemical Markers for Alzheimer’s Disease	New
04/13/2022	*RAD.00067	Quantitative Ultrasound for Tissue Characterization	New
04/13/2022	*SURG.00160	Implanted Port Delivery Systems to Treat Ocular Disease	New
03/25/2022	*TRANS.00038	Thymus Tissue Transplantation	New
04/13/2022	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
04/1/2022	SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
02/24/2022	SURG.00036	Fetal Surgery for Prenatally Diagnosed Malformations	Revised
04/13/2022	SURG.00096	Surgical and Ablative Treatments for Chronic Headaches	Revised
04/13/2022	*SURG.00154	Microsurgical Procedures for the Prevention or Treatment of Lymphedema	Revised

 

Clinical UM Guidelines

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for our members on
March 24, 2022. These guidelines take effect June 4, 2022.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or Revised
04/13/2022	*CG-LAB-20	Thyroid Testing	New
04/13/2022	*CG-LAB-21	Serum Iron Testing	New
04/13/2022	CG-ANC-03	Acupuncture	Revised
04/13/2022	CG-GENE-14	Gene Mutation Testing for Cancer Susceptibility and Management	Revised
04/13/2022	CG-MED-73	Hyperbaric Oxygen Therapy (Systemic/Topical)	Revised
04/13/2022	CG-SURG-36	Adenoidectomy	Revised
02/24/2022	CG-SURG-86	Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection	Revised

ABSCRNU-0337-22

On November 19, 2021, January 4, 2022, and February 25, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 9, 2022	*ING-CC-0211	Kimmtrak (tebentafusp-tebn)	New
June 9, 2022	*ING-CC-0210	Enjaymo (sutimlimab-jome)	New
June 9, 2022	*ING-CC-0213	Voxzogo (vosoritide)	New
June 9, 2022	*ING-CC-0212	Tezspire (tezepelumab-ekko)	New
June 9, 2022	*ING-CC-0086	Spravato (esketamine) Nasal Spray	Revised
June 9, 2022	ING-CC-0157	Padcev (enfortumab vedotin)	Revised
June 9, 2022	ING-CC-0125	Opdivo (nivolumab)	Revised
June 9, 2022	ING-CC-0119	Yervoy (ipilimumab)	Revised
June 9, 2022	*ING-CC-0099	Abraxane (paclitaxel, protein bound)	Revised
June 9, 2022	ING-CC-0120	Kyprolis (carfilzomib)	Revised
June 9, 2022	ING-CC-0126	Blincyto (blinatumomab)	Revised
June 9, 2022	ING-CC-0129	Bavencio (avelumab)	Revised
June 9, 2022	*ING-CC-0090	Ixempra (ixabepilone)	Revised
June 9, 2022	ING-CC-0110	Perjeta (pertuzumab)	Revised
June 9, 2022	ING-CC-0115	Kadcyla (ado-trastuzumab)	Revised
June 9, 2022	ING-CC-0108	Halaven (eribulin)	Revised
June 9, 2022	*ING-CC-0033	Xolair (omalizumab)	Revised
June 9, 2022	*ING-CC-0043	Monoclonal Antibodies to Interleukin-5	Revised
June 9, 2022	ING-CC-0038	Human Parathyroid Hormone Agents	Revised
June 9, 2022	*ING-CC-0186	Margenza (margetuximab-cmkb)	Revised
June 9, 2022	*ING-CC-0124	Keytruda (pembrolizumab)	Revised
June 9, 2022	*ING-CC-0078	Orencia (abatacept)	Revised
June 9, 2022	ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
June 9, 2022	ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
June 9, 2022	*ING-CC-0029	Dupixent (dupilumab)	Revised
June 9, 2022	*ING-CC-0208	Adbry (tralokinumab)	Revised
June 9, 2022	*ING-CC-0209	Leqvio (inclisiran)	Revised
June 9, 2022	*ING-CC-0166	Trastuzumab Agents	Revised
June 9, 2022	*ING-CC-0107	Bevacizumab for Non-ophthalmologic Indications	Revised

ABSCRNU-0335-22

For services beginning on September 1, 2022, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) will be reviewed by myNEXUS.* Through this program, myNEXUS clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate, least restrictive environment.

 

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests on Tuesday, August 30, 2022, for members whose anticipated discharge date is September 1, 2022, or after.

 

Providers are encouraged to request authorization using NexLync. Go to https://portal.mynexuscare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.

 

If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at 833-311-2986.

 

Please note: myNEXUS will not review authorization requests for durable medical equipment (DME), ambulance, and other related services that do not fall under Medicare-covered home healthcare services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

 

To learn more about myNEXUS and upcoming training webinars, visit www.myNEXUScare.com or email Provider_Network@myNEXUScare.com.

 

If you have additional questions, please call the myNEXUS Provider Call Center at 844-411-9622.

 

*Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to September 1, 2022, should be directed to the health plan.

 

* myNEXUS is an independent company providing post-acute benefits management services on behalf of Anthem Blue Cross and Blue Shield.

ABSCRNU-0331-22