 Provider News ConnecticutJanuary 2019 Anthem Connecticut Provider NewsletterConnecting with Anthem and staying informed is easy, fast and convenient with our provider eUpdates. eUpdates feature short topic summaries on late breaking news that impacts providers such as:
- Website updates
- System changes
- Policy updates
- Claims and billing updates
- And more…..
Registration is fast and easy. There is no limit to the number of subscribers who can register for our eUpdates, so your facility or practice can submit as many email addresses as you like. Sign up today! We are committed to offering efficient and streamlined solutions to providers for submitting prior authorizations (PAs). This helps reduce the administrative burden while improving the member experience for their patients.
Our Proactive PA process approves select drugs in real time, using an automated prior authorization (PA) process. Proactive PA uses integrated medical and pharmacy data to seamlessly approve medication prior authorization requests where diagnoses are required. The prior authorization process helps to ensure clinically appropriate use of medications.
Providers can take advantage of the electronic prior authorization (ePA) submission process by logging in at covermymeds.com. Creating an account is FREE, and many prior authorizations are approved in real time. Read more about the ePA submission process.
Additionally, providers may be able to access real-time, patient-specific prescription drug benefits information through their electronic medical record (EMR) system. Learn more about this feature. Has your office received a request for additional information to process a claim for an Anthem member? Those records can be submitted electronically using the Medical Attachments feature in your Availity claims processing portal.
The Medical Attachments feature makes submitting electronic documentation in support of a claim simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.
How to access/setup the solicited medical attachments tool for your office
Availity Administrators must complete these steps:
- From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, follow the prompts and complete the following sections:
- Select Application > choose Medical Attachments Registration
- Provider Management > Select Organization from the drop-down. Add NPIs and/or tax IDs. Multiples can be added separated by spaces or semi-colons.
- Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name.
Submitting medical attachments
Once the above setup is completed, Availity Users will complete these steps:
- Log in to www.availity.com
- Select Claims and Payments > Medical Attachments > Send Attachment Tab
- Complete all required fields of the form
- Attach supporting documentation
- Submit
Need training?
To access additional training for this Availity feature:
- Log in to the Availity Portal at www.availity.com
- At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
- In the new window a list of available topics will open. Locate and click Medical Attachments.
- Under the Recordings section, click View Recording
Need more information?
For more information, contact the Provider Call Center.
We will begin requesting medical records in February via a phone call to your office followed by a fax.
The fax will contain:
1) a cover letter with contact information your office can use to contact us if there are any questions;
2) a member list, which includes the member and HEDIS measure(s) the member was selected for; and
3) an instruction sheet listing the details for each HEDIS measure.
As a reminder, under HIPAA, releasing PHI for HEDIS data collection is permitted and does not require patient consent or authorization. HEDIS and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities [45 CFR 164.506(c) (4)]. For more information, visit www.hhs.gov/ocr/privacy.
HEDIS review is time sensitive, so please submit the requested medical records within five (5) business days.
To return the medical record documentation back to us in the recommended 5-day turnaround time, simply choose one of these three options:
- Upload to our secure portal. This is quick and easy. Logon to www.submitrecords.com, enter the password included with your HEDIS Member List and select the files to be uploaded. Once uploaded you will receive a confirmation number to retain for your records
- Send a secure fax to 888-251-2985
- Mail to us via the US Postal Service to:
Anthem, Inc.
66 E. Wadsworth Park Drive, Suite 110H
Draper, UT 84020
Please contact your Provider Network Representative to let them know if you have a specific person in your organization that we should contact for HEDIS medical records.
Thank you in advance for your support of HEDIS.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
In early 2018, Anthem became one of the first major insurers to reimburse EMS providers for appropriate and medically necessary care billed under HCPCS code A0998 (Ambulance response and treatment, no transport). The code, which has been active since January 2018 for most standard Anthem benefit plans, allows EMS providers to receive reimbursement for treatment rendered in response to an emergency call to a member’s home or scene, when transportation to the hospital emergency room (ER) was not provided. Previously, we reimbursed EMS providers for treatment rendered only when a patient was transported to the ER.
Important reminders:
- The code is currently active and available for EMS use.
- If an EMS provider responds to an emergency call and provides appropriate treatment at-home or on-site without transporting to the ER, code A0998 can be used.
- The EMS provider must render treatment to the patient per EMS protocols which are approved by the medical director at the local or state level.
- Billing of A0998 when treatment is not rendered is not appropriate.
- We will apply medical necessity review to A0998 using coverage guideline CG-ANC-06.
- HCPCS code A0998 applies to all of our commercial health plans, and reimbursement will be made in accordance with the member’s benefits.
Questions?
- For contract questions, please reach out to your contract representative.
- For questions about using code A0998, please reach out to Jay Moore, Senior Clinical Director for Anthem, Inc.
Effective January 1, 2019, the American Medical Association will be replacing the temporary CPT-4 codes used by ABA (applied behavior analyst) treatment services with new permanent CPT-4 codes.
As with all annual CPT-4 coding changes, we will make the necessary updates to all claims and operational systems required for these coding changes. Additional information will be available to all participating ABA providers advising them of any changes to reimbursement or billing as a result of the new CPT codes, once the final and official AMA documentation along with any CMS updates has been provided to health plans and providers.
This conversion table provides guidance on the new codes and their descriptions.
To help expedite the processing of your behavioral health claims with dates of service that span from 2018 into 2019, please split the claims for the 2018 and 2019 service dates. Please review the following information to help ensure your claims are processed accurately and efficiently.
When billing for your behavioral health claims, please bill your claims in the calendar year format. Example: Actual dates of service are December 18, 2018 through January 20, 2019.
Submit two claims:
- Dates of service - December 18, 2018 – December 31, 2018
- Dates of service - January 1, 2019 – January 20, 2019
Effective January 1, 2019 The American Psychological Association (APA) has developed new testing codes and definitions. The former codes will be retired. For more information please visit the APA Practice Organization’s website. Questions can also be emailed to the APA’s Office of Health Care Financing at ohcf@apa.org.
The following new and revised medical policies were endorsed at the November 8, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > scroll down and select ‘Find Resources for [state]’ > Medical Policies and Clinical UM Guidelines.
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies.
Revised medical policies effective November 15, 2018
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00046 - Ipilimumab (Yervoy®)
- DRUG.00071 - Pembrolizumab (Keytruda®)
- DRUG.00075 - Nivolumab (Opdivo®)
- MED.00109 - Corneal Collagen Cross-Linking
- SURG.00120 - Internal Rib Fixation Systems
- SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
Revised medical policies effective December 12, 2018
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00062 - Obinutuzumab (Gazyva®)
- DRUG.00090 - Bezlotoxumab (ZINPLAVA™)
- DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®)
- SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00121 - Transcatheter Heart Valve Procedures
- TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
Archived medical policy effective December 12, 2018
(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)
- DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®)
Revised medical policies effective December 12, 2018
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ADMIN.00001 - Medical Policy Formation
- BEH.00002 - Transcranial Magnetic Stimulation
- DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
- DRUG.00034 - Insulin Potentiation Therapy
- DRUG.00063 - Ofatumumab (Arzerra®)
- DRUG.00074 - Alemtuzumab (Lemtrada™)
- DRUG.00077 - Monoclonal Antibodies to Interleukin-17A
- DRUG.00086 - Mecasermin (Increlex®)
- DRUG.00099 - Cerliponase alfa (Brineura)
- DRUG.00110 - Inotuzumab ozogamicin (Besponsa®)
- DRUG.00111 - Monoclonal Antibodies to Interleukin-23
- DRUG.00116 - Vestronidase alfa (Mepsevii™)
- DRUG.00118 - Copanlisib (Aliqopa®)
- GENE.00006 - Epithelial Growth Factor Receptor (EGFR) Testing
- GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
- GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
- GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
- GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility
- GENE.00035 - Genetic Testing for TP53 Mutations
- GENE.00044 - Analysis of PIK3CA Status in Tumor Cells
- LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
- LAB.00029 - Rupture of Membranes Testing in Pregnancy
- MED.00041 - Microvolt T-Wave Alternans
- MED.00055 - Wearable Cardioverter Defibrillators
- MED.00085 - Antineoplaston Therapy
- MED.00121 - Implantable Interstitial Glucose Sensors
- RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
- RAD.00036 - MRI of the Breast
- RAD.00061 - PET/MRI
- RAD.00065 - Radiostereometric Analysis
- SURG.00019 - Transmyocardial Revasculareization (TMR)
- SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
- SURG.00052 - Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
- SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
- SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
- SURG.00130 - Annulus Closure After Discectomy
- SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
- TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
- TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
- TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
Revised medical policies effective December 27, 2018
(The following policies were updated with new procedure and/or diagnosis codes.)
- DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
- DRUG.00080 - Monoclonal Antibodies for the Treatment of Eoslinophilic Asthma
- DRUG.00108 - Edaravone (Radicava®)
- DRUG.00109 - Durvalumab (Imfinzi™)
- GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
- GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
- GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
- LAB.00011 - Analysis of Proteomic Patterns
- LAB.00019 - Serum Markers for Liver Fibrosis in the Evalution and Monitoring of Patients with Chronic Liver Disease
- MED.00109 - Corneal Collagen Cross-Linking
- MED.00111 - Intracardiac Ischemia Monitoring
- MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
- MED.00120 - Voretigene Neparvovec
- MED.00123 - Axicabtagene ciloleucel (Yescarta®)
- MED.00124 - Tisagenlecleucel (Kymriah®)
- OR.PR.00005 - Upper Extremity Myoelectric Orthoses
- SURG.00007 - Vagus Nerve Stimulation
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
- SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
- SURG.00111 - Axial Lumbar Interbody
- SURG.00113 - Artifical Retinal Devices
- SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- SURG.00150 - Leadless Pacemaker
- THER-RAD.00009 - Intraocular Epirentinal Brachytherapy
Revised medical policies effective January 1, 2019
(The following policies were updated with new procedure and/or diagnosis codes.)
- DRUG.00096 - Ibalizumab-uiyk (Trogarzo™)
Archived medical policy effective January 1, 2019
(The following policy has been archived and has been replaced by AIM guidelines.)
- SURG.00066 - Percutaneous Thermal Neurolysis for Chronic Back Pain
Archived medical policies effective January 3, 2019
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- MED.00100 - Diaphragmatic/ Phrenic Nerve Stimulation and Diaphragm Pacing Systems
- RAD.00002 - Positron Emission Tomography (PET) and PET/CT Fusion
Revised medical policies effective April 1, 2019
(The following policies were updated with procedure and/or diagnosis codes and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
Revised medical policy effective April 1, 2019
(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- DRUG.00071 - Pembrolizumab (Keytruda®)
- SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
New medical policy effective April 1, 2019
(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
The following new and revised medical policies were endorsed at the November 8, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > scroll down and select ‘Find Resources for [state]’ > Medical Policies and Clinical UM Guidelines.
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Revised clinical guideline effective November 15, 2018
(The following adopted guideline was revised to expand medical necessity indications or criteria
- CG-DRUG-88 - Dupilumab (Dupixent®)
Revised clinical guidelines effective December 12, 2018
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-62 - Fulvestrant (FASLODEX®)
- CG-DRUG-63 - Levoleucovorin Products
- CG-DRUG-65 - Tumor Necrosis Factor Antagonists
- CG-DRUG-78 - Antihemophilic Factor and Clotting Factors
- CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema
- CG-GENE-03 - BRAF Mutation Analysis
- CG-SURG-60 - Cervical Total Disc Arthroplasty
- CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy
Revised clinical guidelines effective December 12, 2018
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-DRUG-38 - Pemetrexed (Alimta®)
- CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase)
- CG-DRUG-44 - Pegloticase (Krystexxa®)
- CG-DRUG-45 - Octreotide Acetate (Sandostatin, Sandostatin LAR)
- CG-DRUG-54 - Agalsidase beta (Fabrazyme®)
- CG-DRUG-64 - FDA-Approved Biosimilar Products
- CG-DRUG-66 - Panitumumab (Vectibix®)
- CG-DRUG-70 - Eribulin mesylate (Halaven®)
- CG-DRUG-71 - Ziv-aflibercept (Zaltrap®)
- CG-DRUG-75 - Romiplostim (Nplate®)
- CG-DRUG-76 - Plerixafor Injection (Mozobil™)
- CG-DRUG-79 - Siltuximab (Sylvant®)
- CG-DRUG-80 - Cabazitaxel (Jevtana)
- CG-DRUG-87 - Vedolizumab (Entyvio®)
- CG-MED-19 - Custodial Care
- CG-MED-26 - Neonatal Levels of Care
- CG-MED-67 - Melanoma Vaccines
- CG-MED-68 - Therapeutic Apheresis
- CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services
- CG-SURG-60 - Cervical Total Disc Arthroplasty
- CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver
- CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors
Revised clinical guideline effective December 12, 2018
(The following adopted guideline was updated with new procedure and/or diagnosis codes.)
- CG-DRUG-16 - White Blood Cell Growth Factors
Revised clinical guidelines effective December 27, 2018
(The following adopted guidelines were updated with new procedure and/or diagnosis codes.)
- CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
- CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
- CG-DRUG-29 - Hyaluronan Injections
- CG-DRUG-61 - Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
- CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
- CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions
- CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications
- CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
Archived clinical guideline effective January 1, 2019
(The following adopted guideline has been archived and has been replaced by AIM guidelines.)
- CG-SURG-60 - Cervical Total Disc Arthroplasty
Revised clinical guidelines effective January 1, 2019
(The following adopted guidelines were revised and had no significant changes to the policy position or criteria.)
- CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CG-MED-65 - Manipulation Under Anesthesia
Adopted clinical guidelines effective January 3, 2019
(The following guidelines were previously medical policies and have been adopted and have no significant changes.)
- CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
- CG-MED-80 - Positron Emission Tomography (PET) and PET/CT Fusion
Revised clinical guidelines effective April 1, 2019
(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)
- CG-GENE-01 - Janus Kinase 2 (JAK2) V617F and JAK2 exon 12 Gene Mutation Assays
- CG-SURG-27 - Sex Reassignment Surgery
- CG-SURG-61 - Cryosurgical Ablation of Solid Tumors Outside the Liver
In the October 2018 issue of our provider newsletter in the article titled ‘Clinical guideline updates are available on anthem.com’, we advised that the following guidelines previously unadopted would become effective January 1, 2019. Recently, a decision was made that these guidelines will not become effective in January, and will remain unadopted.
- CG-DME-09 - Continuous Local Delivery of Analgesia to Operative Sites using and Elastromeric Infusion Pump during the Post-operative Period
- CG-DME-13 - Lower Limb Prosthesis
- CG-DME-21 - External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
- CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
- CG- REHAB-02 - Outpatient Cardiac Rehabilitation
We are committed to investing in primary care, rewarding coordinated, patient-centered care, and promoting proactive chronic care management. In recognition of the time-intensive nature of this work, we will reimburse chronic care management and advance care planning services for Commercial health plans effective for claims processed on or after February 23, 2019.
- Chronic care management (CCM) is care rendered by a physician or non‐physician health care provider and their clinical staff, once per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only one practitioner can bill a CCM service per service period (month). Three CCM codes are included in this payment policy change: 99490, 99487and 99489.
- Advance care planning (ACP) is a face-to-face service between a physician or other qualified health care professional and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time. No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary. Two ACP codes are included in the payment policy change: 99497 and 99498
Anthem requires patient consent prior to CCM or ACP service(s) being provided. Please refer to the current Claims Requiring Additional Documentation policy for more information at Reimbursement Policy.
For more information, review our Bundled Services and Supplies policy dated February 23, 2019 by visiting the Reimbursement Policy page at anthem.com/provider. We continually monitor and update the list of drugs not approved by the Food and Drug Administration (FDA), which are considered non-covered under prescription drug benefits. When drugs are added to this list, we notify impacted members that the drug is not FDA approved and will no longer be covered.
Effective December 1, 2018, these drugs were added to our list of drugs not approved by the FDA. For new members just beginning an Anthem plan or not yet having used one of these non-FDA-approved drugs, coverage for these drugs ended December 1, 2018.
Existing members who had been identified as already using at least one of the drugs added to the list received a letter to let them know their drug(s) will no longer be covered after December 31, 2018. However, if the patient had a prior authorization for a drug on this list, coverage for that drug continued until the prior authorization expired on December 31, 2018.
We recently introduced a redesigned monthly Explanation of Benefits (EOB) to Medicare Advantage members.
The new EOB includes:
- Personalized tips to help members save on health care expenses
- Preventive care checklist — to point out opportunities for screenings or other care
- Alerts when a claim needs immediate attention
If you or your members have any questions about how to read the new EOB, please call the number on the back of the member ID card. |