You may submit all your prior authorizations in one application on Availity.com.

You may already be submitting your prior authorizations through the Availity multi-payer Authorization application — taking advantage of the time savings and speed to care through digital authorization submissions. Beginning in March, you can submit both your physical health and behavioral health prior authorizations through one Authorization application on Availity.com.

You can still access the Interactive Care Reviewer (ICR) to review cases that were submitted through that application. You will also continue to use ICR to submit an appeal or authorization for medical specialty Rx.

Using the Availity Authorization application to submit your behavioral health prior authorizations will not be much different from the process you follow today. You may enjoy more intuitive screens or learn sooner if an authorization is required — but the digital submission process is still the very best way to submit your prior authorization and the fastest way to care for our members.

Training is available

If you aren’t already familiar with Availity Authorization, training is available. Select Availity Authorization Training to enroll for an upcoming live webcast or to access an on-demand recording.

Now, give it a try!

Accessing the Availity for authorization is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, log on to Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals.

The following new Medical Policies were endorsed at the November 9, 2023, Medical Policy & Technology Assessment Committee (MPTAC) meeting. This, and all Anthem’s Medical Policies and Clinical Guidelines, are available at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select your state. Then, select View Medical Policies & Clinical UM Guidelines.

To view Medical Policies and Clinical Utilization Management Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program^® [FEP]), visit fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policy effective May 1, 2024

The following policy is new:

• RAD.00068 Myocardial Strain Imaging

Revised Medical Policies effective May 1, 2024

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• MED.00120 Gene Therapy for Ocular Conditions
• SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00097 Scoliosis Surgery
• SURG.00142 Genicular Procedures for Knee Pain

Effective for dates of service on and after May 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

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

• Access the ProviderPortal_SM 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 via Availity.com.

If you have questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

With your help, we can continually build towards a future of shared success.

As part of our ongoing quality improvement efforts, we will be implementing a new Genetic Testing (GT) claim to authorization match enhancement that will ensure GT panels billed have a corresponding authorization. This enhanced match logic will be effective by May 1, 2024. Labs that bill panels with codes in excess of what has been authorized may receive a full claim denial. The goal of this enhanced match logic is to ensure tests performed are authorized and meet medical necessity requirements.

Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. 

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call the number on the back of their patient’s member ID card .for assistance with PA requirements.

Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call the number on the back of their patient’s member ID card .for assistance with PA requirements.

Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s).  The medical code(s) listed below will require PA for Anthem Blue Cross and Blue Shield members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. 

Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call the number on the back of their patient’s member ID card for Provider Services.

Beginning with dates of service on or after May 1, 2024, Anthem will implement a new reimbursement policy titled Modifier Usage — Facility based on the code-set combinations submitted with the correct modifiers. This reimbursement policy identifies the following three different types of facility modifiers:

• Reimbursement modifiers affect payment and denote circumstances when an increase or reduction is appropriate for the service provided.
• Informational modifiers impacting reimbursement determine if the service provided will be reimbursed or denied.
• Informational modifiers not impacting reimbursement are used for documentation purposes.

The Related Coding section of the policy includes a Facility Modifier code list which identifies the modifier, the modifier description, and any related reimbursement policies. The Facility Modifier code list also includes six modifiers that do not have associated reimbursement policies. These modifiers indicate a reduced service or different equipment was used for the service. These modifiers will result in a reduction when billed on a facility claim. 

 For specific policy details, visit the reimbursement policy page at anthem.com.

Beginning with dates of service on or after April 1, 2024, Anthem will not reimburse for the following when billed on a UB-04:

• Consultation CPT^® codes 99242–99245, 99251–99255
• Prolonged Services codes 99354–99359, 99415–99417 and G2212

For appropriate billing guidelines of Consultation and Prolonged Services CPT codes, please refer to the corresponding professional Reimbursement Policies:

• Prolonged Services
• Consultation Services

 For specific policy details, visit the reimbursement policy page at anthem.com:

Specialty pharmacy updates for Anthem are listed below

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Update: In the May 2023 edition of Provider News, we announced prior authorization for Adstiladrin will be effective August 2023. Review of Adstiladrin is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

The following Clinical Criteria documents were endorsed at the November 17, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective May 1, 2024

The following Clinical Criteria are new:

• CC-0253 Aphexda (motixafortide)
• CC-0254 Zilbysq (zilucoplan)

Revised Clinical Criteria effective May 1, 2024

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CC-0002 Colony Stimulating Factor Agents
• CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
• CC-0011 Ocrevus (ocrelizumab)
• CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• CC-0020 Natalizumab Agents (Tysabri, Tyruko)
• CC-0032 Botulinum Toxin
• CC-0041 Complement Inhibitors
• CC-0042 Monoclonal Antibodies to Interleukin-17
• CC-0050 Monoclonal Antibodies to Interleukin-23
• CC-0062 Tumor Necrosis Factor Antagonists
• CC-0063 Ustekinumab Agents (Stelara, Wezlana)
• CC-0064 Interleukin-1 Inhibitors
• CC-0065 Agents for Hemophilia A and von Willebrand Disease
• CC-0066 Monoclonal Antibodies to Interleukin-6
• CC-0068 Growth Hormone
• CC-0071 Entyvio (vedolizumab)
• CC-0078 Orencia (abatacept)
• CC-0086 Spravato (esketamine) Nasal Spray
• CC-0170 Uplizna (inebilizumab-cdon)
• CC-0173 Enspryng (satralizumab-mwge)
• CC-0174 Kesimpta (ofatumumab)
• CC-0182 Iron Agents
• CC-0199 Empaveli (pegcetacoplan)
• CC-0226 Elahere (mirvetuximab)

Effective for dates of service on and after May 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.