 Provider News ConnecticutJanuary 2022 Anthem Connecticut Provider NewsThe Reimbursement Requirements and Policies chapter of the Connecticut Provider Manual has been updated to reflect the information provided in the June 1, 2021 issue of Provider News with regard to Evaluation and Management (E&M) Services. This language is consistent with the language in the 2020 provider manual, as well as articles published in the January 2021 and June 2021 issues of Provider News. You can download the Connecticut Provider Manual here.
Parents may not understand the importance of taking their children to the doctor when they are healthy. The benefits are documented by the American Academy of Pediatrics (AAP)1 as well as the Centers for Disease Control and Prevention2 and it all starts with a recommendation by you, the trusted physician. Share these benefits with parents during regularly scheduled well-visits, or even during sick visits, to reinforce the importance of staying on track:
- Regular wellness visits help ensure children receive scheduled immunizations that prevent illness. It is also a great opportunity to discuss nutrition and safety in the home.
- Growth and development. Evaluating children for growth and development enables parents to see how much their children have grown since the last visit. It is also an opportunity to share the children’s development, to discuss milestones, social behaviors, and learning.
- Raising concerns. Offering parents an opportunity to share concerns at the start of the visit will help in your evaluation of the patient. They may want to talk about development, sleep and eating habits and behaviors.
- Team approach. Regular visits create strong, trustworthy relationships among physician, parent, and child. The AAP supports well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental, and social health of a child.
Measure up: Well-child visits in the first 30 months of life (W30)
This HEDIS® measure is described as the percentage of members who had to the following number of well-child visits with a PCP during the last 15 months. These rates are reported:
- Well-child visits in the first 15 months: Six or more well-child visits with children who turned age 15 months during the measurement year.
- Well-child visits for ages 15 to 30 months: Two or more well-child visits with children who turned age 30 months during the measurement year.
Tips
- Telehealth visits are acceptable in meeting the measurement requirements.
- Consider scheduling well-child visits in advance of the child reaching the age for the visit.
Coding
- ICD-10:110, Z00.111, Z00.121, Z00.129, Z00.2, Z00.3, Z02.5, Z76.1, Z76.2
- HCPCS: G0438-G0439, S0302
- CPT: 99381-99382, 99391-99392, 99461
You may already be familiar with the Availity multi-payer Authorization app because thousands of providers are already using it for submitting prior authorizations for other payers. Anthem is eager to make it available to our providers, too. In 2022, you can begin using the same authorization app you use for other payers. We hope to make it easier to submit prior authorization requests to Anthem.
ICR is still available
If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We’ve developed a pathway to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization app.
Innovation in progress
While we grow the Availity Authorization app to provide you with Anthem-specific information, you can still access ICR for:
- Appeals
- Behavioral health authorizations
- FEP authorizations
- Medical specialty Rx
Notices in the Availity Authorization App will guide you through the process for accessing ICR for Alternate Authorization/Appeals functions.
Training is available
If you aren’t already familiar with the Availity Authorization app, training is available.
Wednesday, January 5, 2022 - 11 a.m.
Tuesday, January 11, 2022 - 3 p.m.
Thursday, January 20, 2022 - Noon
Wednesday, January 26, 2022 - Noon
Tuesday, January 25, 2022 - 3 p.m.
From Help & Training select Get Trained to access the Availity Learning Center. You can use “AvAuthRef” for a keywork search or select the Session tab to see all upcoming live webinars. You can also log onto Availity.com and view the webinar at your convenience.
Give it a try!
Accessing the Availity Authorization app is easy. Just log onto Availity.com and the Authorization icon is on the home screen. You can also access the app through the Patient Registration tab by selecting Authorizations and Referrals.
When you use the Availity Authorization app, you will know if a prior authorization is required in six easy steps and in fewer than five minutes. If a prior authorization is not needed, the message “No Auth Required” will return. This submission will be saved to your dashboard for future reference. If authorization is needed, just continue with the prior authorization submission. The entire submission process takes less time than it would to send an authorization by fax and is much quicker than chatting with provider services.
Did you know that digital authorizations are considered a high priority? Submitting your pressing authorizations through the Availity Authorization app augments our process, helping to reduce unnecessary delays to your patient’s care.
You can now submit prior authorizations in one place for all payers. The Availity Authorization app is multi-payer. This means you no longer have to toggle between Anthem’s Interactive Care Recorder (ICR) and the Availity Authorization app to submit apps for all payers.
AIM authorization for radiology services? No problem! The Availity Authorization app is set up for radiology service authorization submissions. Coming later in 2022, you can submit all of your AIM authorizations through the app.
Access the Availity Authorization app for Anthem submissions in 2022. Log onto Availity.com and select the Authorizations app from the home screen or use the Patient Registration tab to select Authorizations & Referrals through the multi-payer app.
ICR is still accessible to review previously submitted authorizations. You will also continue to use ICR for behavioral health authorizations, FEP authorizations and authorizations for medical specialty Rx. Until we fully integrate Anthem-specific functions in the Availity Authorization app, you will also continue to use ICR for appeals as well.
How do you access ICR? That’s easy, too. We have added a landing page in the Availity Authorization app that offers a direct link to your ICR dashboard. Just select the Alternate Authorizations/Appeals button on the landing page.
Not familiar with the Availity Authorization app? Training is convenient and available through live webinars or recorded sessions for self-service learning. To sign-up for training log onto Availity.com and from the top toolbar select Help & Training then Get Trained. Use “AvAuthRef” in the search bar or select the Session tab to see all upcoming live webinars.
Wednesday, January 5, 2022 - 11 a.m.
Tuesday, January 11, 2022 - 3 p.m.
Thursday, January 20, 2022 - Noon
Wednesday, January 26, 2022 - Noon
Tuesday, January 25, 2022 - 3 p.m.
Give it a try! If you’re not enrolled on Availity go to Availity.com/provider-portal-registration. Availity is free to Anthem providers, saves time, reduces costs and offers a seamless digital transaction experience.
The following new and revised medical policies and clinical guidelines were endorsed at the November 11, 2021, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'
To view medical policies and 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®)), please visit www.fepblue.org > Policies & Guidelines.
Medical policy updates
Archived medical policies effective November 18, 2021
(The following policies have been archived.)
- MED.00095 Anterior Segment Optical Coherence Tomography
- MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
- OR-PR.00004 Partial-Hand Myoelectric Prosthesis [Content moved to CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices]
Revised medical policies effective November 18, 2021
(The following policies were revised to expand medical necessity indications or criteria.)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
Archived medical policies effective December 29, 2021
(The following policies have been archived.)
- GENE.00036 Genetic Testing for Hereditary Pancreatitis [Content moved to CG-GENE-13 Genetic Testing for Inherited Diseases]
- GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing [Content moved to CG-GENE-13 Genetic Testing for Inherited Diseases]
- MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium [Content moved to TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products]
Revised medical policy effective December 29, 2021
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00037 Treatment of Varicose Veins (Lower Extremities)
Revised medical policies effective December 29, 2021
(The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- ADMIN.00001 Medical Policy Formation
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00016 Gene Expression Profiling for Colorectal Cancer
- GENE.00025 Proteogenomic Testing for the Evaluation of Malignancies
- GENE.00037 Genetic Testing for Macular Degeneration
- GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
- GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
- GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
- LAB.00024 Immune Cell Function Assay
- LAB.00026 Systems Pathology Testing for Prostate Cancer
- LAB.00034 Serological Antibody Testing For Helicobacter Pylori
- LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
- MED.00002 Selected Sleep Testing Services
- MED.00065 Hepatic Activation Therapy
- MED.00091 Rhinophototherapy
- MED.00092 Automated Nerve Conduction Testing
- MED.00097 Neural Therapy
- MED.00110 Silver-based Products for Wound and Soft Tissue Applications [Moved content addressing autologous skin-, blood- or bone marrow-derived products for wound and soft tissue applications to TRANS.00035 Other Stem Cell Therapy. Moved content addressing bioengineered autologous skin-derived products (for example, SkinTE, MyOwn Skin) to SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue.]
- MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
- MED.00116 Near-Infrared Spectroscopy Scanning for Brain Hematoma Screening
- MED.00121 Implantable Interstitial Glucose Sensors
- MED.00122 Wilderness Programs
- MED.00128 Insulin Potentiation Therapy
- MED.00129 Gene Therapy for Spinal Muscular Atrophy
- MED.00130 Surface Electromyography Devices for Seizure Monitoring
- MED.00131 Electronic Home Visual Field Monitoring
- RAD.00036 MRI of the Breast
- RAD.00053 Cervical and Thoracic Discography
- RAD.00065 Radiostereometric Analysis (RSA)
- REHAB.00003 Hippotherapy
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting [Incorporated position statement addressing bioengineered autologous skin-derived products from MED.00110 Silver-based Products for Wound and Soft Tissue Applications into this document.]
- SURG.00019 Transmyocardial Revascularization
- SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00044 Breast Ductal Examination and Fluid Cytology Analysis
- SURG.00062 Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
- SURG.00073 Epiduroscopy
- SURG.00079 Nasal Valve Suspension
- SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
- SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke
- SURG.00099 Convection Enhanced Delivery of Therapeutic Agents to the Brain
- SURG.00100 Cryoablation for Plantar Fasciitis and Plantar Fibroma
- SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
- SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
- SURG.00123 Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
- SURG.00130 Annulus Closure After Discectomy
- SURG.00138 Laser Treatment of Onychomycosis
- SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- SURG.00146 Extracorporeal Carbon Dioxide Removal
- SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
- THER-RAD.00008 Neutron Beam Radiotherapy
- TRANS.00008 Liver Transplantation
- TRANS.00009 Lung and Lobar Transplantation
- TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
- TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
- TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
- TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
- TRANS.00026 Heart/Lung Transplantation
- 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.00033 Heart Transplantation
- TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
- TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products [Moved “Autologous Skin, Blood or Bone Marrow derived Products for Wound and Soft Tissue Applications” content from MED.00110 Silver-based Products for Wound and Soft Tissue Applications to this document. Moved content from MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium to this document.]
Revised medical policies effective December 29, 2021
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- GENE.00023 Gene Expression Profiling of Melanomas
- LAB.00031 Advanced Lipoprotein Testing
- MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
- MED.00102 Ultrafiltration in Decompensated Heart Failure
- MED.00111 Intracardiac Ischemia Monitoring
- MED.00112 Autonomic Testing
- SURG.00007 Vagus Nerve Stimulation
- SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
- SURG.00045 Extracorporeal Shock Wave Therapy
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00121 Transcatheter Heart Valve Procedures
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
New medical policies effective April 1, 2022
(The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- DME.00044 Wheelchair Mounted Robotic Arm Attachment
- MED.00138 Wearable Devices for Stress Relief and Management
Revised medical policies effective April 1, 2022
(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.00099 Navigational Bronchoscopy
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00097 Scoliosis Surgery
Clinical guideline updates
Revised clinical guideline effective November 18, 2021
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices [Moved content addressing partial-hand prosthesis from OR-PR.00004 Partial-Hand Myoelectric Prosthesis to this document.]
Unadopted clinical guidelines effective December 1, 2021
(The criteria in the following guidelines will no longer be applied.)
- CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs–Ultra Lightweight
- CG-DME-42 Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
- CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance
- CG-SURG-12 Penile Prosthesis Implantation
- CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
- CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
- CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
Revised clinical guideline effective December 29, 2021
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-DME-06 Compression Devices for Lymphedema
Revised clinical guidelines effective December 29, 2021
(The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- CG-ANC-04 Ambulance Services: Air and Water
- CG-ANC-07 Inpatient Interfacility Transfers
- CG-BEH-14 Intensive In-Home Behavioral Health Services
- CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
- CG-DME-31 Wheeled Mobility Devices: Wheelchairs–Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
- CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CG-GENE-13 Genetic Testing for Inherited Diseases [Moved content of GENE.00036 Genetic Testing for Hereditary Pancreatitis and GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing to this document.]
- CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis
- CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
- CG-GENE-18 Genetic Testing for TP53 Mutations
- CG-GENE-19 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
- CG-LAB-13 Skin Nerve Fiber Density Testing
- CG-MED-19 Custodial Care
- CG-MED-23 Home Health
- CG-MED-38 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
- CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
- CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
- CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
- CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- CG-SURG-72 Endothelial Keratoplasty
- CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-SURG-77 Refractive Surgery
- CG-SURG-92 Paraesophageal Hernia Repair
- CG-SURG-94 Keratoprosthesis
- CG-SURG-96 Intraocular Telescope
- CG-SURG-105 Corneal Collagen Cross-Linking
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)
Revised clinical guidelines effective December 29, 2021
(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
- CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
- CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
- CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
- CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
- CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
Archived clinical guidelines effective December 29, 2021
(The following guidelines have been archived.)
- CG-MED-77 SPECT/CT Fusion Imaging
- CG-MED-87 Single Photon Emission Computed Tomography Scans for Non-cardiovascular Indications
Unadopted clinical guidelines effective January 1, 2022
(The criteria in the following guidelines will no longer be applied.)
- CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CG-SURG-77 Refractive Surgery
- CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)
Revised clinical guideline effective April 1, 2022
(The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
Beginning with dates of service on or after April 1, 2022, we will update the policy to indicate that we will calculate reimbursement for time-based anesthesia services as follows:
- the number of minutes reported will be divided by 15 (minutes) and rounded to the nearest tenth to provide a unit of measure.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
BlueHPN® is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with more than 50 local networks across the country. These local networks are then connected to the national chassis to form a national Blue HPN network.
First launched in 2021, even more members are covered by plans with access to the BlueHPN for 2022.
In Connecticut, the high performance network is built around the Hartford metro area. You can use our Find a Doctor / Find Care provider directory at www.anthem.com to identify providers participating in the BlueHPN.
Member ID cards and other plan materials (e.g., marketing communications) will feature one small change for year 2022: BlueHPN is now a single word rather than two. As was the case in 2021, you may see members accessing this network through a BlueHPN national employer plan, sold as an EPO or EPO HSA/HRA plan on an EPO Network. Under EPO plans, out of network benefits are limited to emergency or urgent care. Members may be required to select a primary care provider, but PCP referrals are not required for specialty care.
ID cards for these plans will show a ‘BlueHPN’ label inside a suitcase icon, as shown in the mock-up sample ID card below.
To view the 2022 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to fepblue.org then click Tools & Resources at the top of the page, and then click Brochures & Resources. Here you will find Plan Brochures, Plan Summaries, and Quick Reference Guides on information for year 2022. For questions, please contact FEP Customer Service at 800-438-5356.
Submitting prior authorizations is now easier and multi-payer
We know how much easier it is when you have access to digital apps that streamline your work. Thousands of providers already use the Availity* Authorization app to submit prior authorizations for other payers. Now, we want to make it easier to submit prior authorization requests to Anthem by making the app available in 2022 to our providers as well.
ICR is still available
If you need to refer to an authorization that was submitted through the Interactive Care Reviewer (ICR), you still have access to that information. We have developed a pathway for you to access your ICR dashboard — You simply follow the prompts provided through the Availity Authorization app.
Innovation in progress
While we grow the Availity Authorization app to provide even greater functionality and to expand Anthem-specific prior authorizations, we have provided access to ICR for:
- Appeals
- Behavioral health authorizations
- Federal Employee Program authorizations
- Medical specialty pharmacy authorizations
Notices in the Availity Authorization app will guide you through the process for accessing ICR for these Alternate Authorization/Appeal functions.
Begin submitting digital prior authorizations through the Authorization app in 2022
If you aren’t already familiar with the Availity Authorization app, live training and recorded webinars are available.
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Date
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Time (All training sessions are one hour)
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Wednesday, January 5, 2022
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11 a.m.
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Tuesday, January 11, 2022
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3 p.m.
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Thursday, January 20, 2022
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Noon p.m.
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Tuesday, January 25, 2022
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Noon p.m.
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Wednesday, January 26, 2022
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3 p.m.
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You can always log onto availity.com to view the webinars at your convenience. From Help & Training, select Get Trained to access the Availity Learning Center. Select the Session tab to see all upcoming live webinars.
Tip: To find the authorization training faster, use keyword AvAuthRef in the search field.
Give it a try
Eliminate the time and costs associated with faxing prior authorizations by using the Availity Authorization app. It’s easy, convenient, and available when you are, 24/7.
Get access by logging onto availity.com. Under the Patient Registration tab, select Authorizations & Referrals. The app is easy to navigate with intuitive functions that walk you through the submission.
Tips: You will need to have the Authorization Role assignment in order to access the app and to submit prior authorizations. Your organization’s Availity administrator can assign the role to you.
If you have any questions, reach out to Availity at 800-282-4548.
The HEDIS® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality health-care services.
The ECDS Reporting Standard provides a method to collect, and report structured electronic clinical data for HEDIS quality measurement and improvement.
Benefits to providers:
- Reduced burden of medical record review for quality reporting
- Improved health outcomes and care quality due to greater insights for more specific patient-centered care
ECDS reporting is part of the National Committee for Quality Assurance’s (NCQA) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures.
Learn more about NCQA’s digital quality system and what it means to you and your practice.
ECDS measures
The first publicly reported measure using the HEDIS ECDS Reporting Standard is the Prenatal Immunization Status (PRS) measure. In 2022, NCQA will include the PRS measure in Health Plan Ratings for Medicaid and Commercial plans for measurement year 2021.
For HEDIS measurement year 2022, the following measures can be reported using ECDS:
- Childhood Immunization Status (CIS-E)*
- Immunizations for Adolescents (IMA-E)*
- Breast Cancer Screening (BCS-E)
- Colorectal Cancer Screening (COL-E)
- Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
- Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)*
- Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
- Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
- Depression Remission or Response for Adolescents and Adults (DRR-E)
- Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
- Adult Immunization Status (AIS-E)
- Prenatal Immunization Status (PRS-E) (Accreditation measure for 2021)
- Prenatal Depression Screening and Follow-Up (PND-E)
- Postpartum Depression Screening and Follow-Up (PDS-E)
* Indicates that this is the first year that the measure can be reported using ECDS
Of note, NCQA added the ECDS reporting method to three existing HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening and Follow-up Care for Children Prescribed ADHD Medication. Initially, the ECDS method will be optional, which provides health plans an opportunity to try out reporting using the ECDS method before it is required to transition to ECDS only in the future.
Effective December 1, 2021, Anthem will prefer the referring physician name and NPI to be included on professional claims for home infusion therapy (HIT) services in fields 17 and 17a on the CMS-1500 claim form.
Providers should report the referring physician information in accordance with the Anthem guidelines in the Electronic Data Interchange (EDI) Companion Guide for claims submitted electronically.
Thank you for your assistance in our ongoing efforts to promote accurate claims processing and payment. We continue to be dedicated to delivering access to quality care for our members, providing higher value to our customers, and helping improve the health of our communities.
If you have questions regarding this process, contact your Network Manager.
Effective January 1, 2022, IngenioRx/CVS Specialty Pharmacy* will no longer distribute the brand name drug Botox®. However, Botox will still be available to Anthem members through other vendors.
Please note:
- This is not a change in member benefits. This is a change in the Botox vendor only.
- If the member is not using IngenioRx/CVS Specialty Pharmacy to obtain Botox, no action is needed.
For Botox managed under a Medicare member’s part B (medical) benefit
Providers should be using buy and bill for any Medicare member who currently receive Botox through their part B (medical) benefit. If your patient is receiving Botox using their part B benefit and is receiving their prescription from IngenioRx/CVS Specialty pharmacy, effective January 1, 2022, IngenioRx/CVS Specialty will no longer filled the prescription. As of January 1, 2022, you will need to buy this drug and bill your patient’s health plan.
If you have questions regarding a Medicare member’s part B benefits, call Provider Services using the information on the back of the member’s ID card.
For Botox managed under a Medicare member’s part D (pharmacy) benefit
Effective January 1, 2022, Medicare members who currently receive Botox through IngenioRx/CVS Specialty Pharmacy using their part D (pharmacy) benefit must change to another in-network specialty or retail pharmacy that can obtain and dispense Botox.
If you have questions regarding a Medicare member’s part D benefit, call Pharmacy Member Services using the information on the back of the member’s ID card.
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