June 2018 Connecticut newsletter

Contents

AdministrativeCommercialJune 19, 2018

EDI collaboration with Availity effective June 1, 2018

AdministrativeCommercialJune 19, 2018

Misrouted protected health information (PHI)

AdministrativeCommercialJune 22, 2018

Grievance and appeal update

AdministrativeCommercialJune 19, 2018

Member identification cards streamlined

AdministrativeCommercialJune 19, 2018

Sign-up today for Network eUPDATE – it’s free!

AdministrativeCommercialJune 22, 2018

Anthem PPACA Exchange Network Consolidations

AdministrativeCommercialJune 19, 2018

Verifying eligibility for expanded hospice benefits

AdministrativeCommercialJune 19, 2018

Durable medical equipment miscellaneous code E1399 reminder

Behavioral HealthCommercialJune 22, 2018

MCG Care Guidelines adopted for behavioral health services

Behavioral HealthCommercialJune 19, 2018

Outpatient behavioral health therapy visits

Behavioral HealthCommercialJune 22, 2018

Crisis stabilization

Medical Policy & Clinical GuidelinesCommercialJune 22, 2018

Medical policy and clinical guidelines updates are available on anthem.com

Reimbursement PoliciesCommercialJune 22, 2018

Durable Medical Equipment professional reimbursement policy reminders

Reimbursement PoliciesCommercialJune 19, 2018

Review of reimbursement policies – professional

Reimbursement PoliciesCommercialJune 22, 2018

Update to Use of a Non-Participating Provider Advance Patient Notice Policy

State & FederalMedicare AdvantageJune 19, 2018

Cologuard covered for Medicare Advantage members

State & FederalMedicare AdvantageJune 19, 2018

Peer-to-peer process can help clarify clinical record

State & FederalMedicare AdvantageJune 19, 2018

MA home health network to be delegated to myNEXUS

State & FederalMedicare AdvantageJune 19, 2018

Medication adherence incentive offered to EPHC providers

State & FederalMedicare AdvantageJune 19, 2018

Keep up with Medicare news

AdministrativeCommercialJune 19, 2018

Clinical practice and preventive health guidelines available on anthem.com

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research.

 

All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website at anthem.com/provider > Select a state > Find Resources for [state] > Health & Wellness tab > Practice Guidelines.

AdministrativeCommercialJune 19, 2018

EDI collaboration with Availity effective June 1, 2018

We recently moved into a strategic collaboration with Availity to serve as our designated EDI Gateway and E-solutions Service Desk. The following are points to be aware of with this change:

 

  • Beginning June 1, 2018, you will be able to manage all changes and new setup requests for the electronic remittance advice (835) through the Availity Portal.
  • To register or manage account changes for electronic funds transfers (EFT) only, please continue to use the EnrollHub at https://solutions.caqh.org
  • If you submit your electronic transactions directly to us and have your own practice management software, Availity provides trading partner services and access to Portal tools through an easy setup experience.
  • If you use a clearinghouse, they will work with Availity on your behalf.
  • We are working with Availity to develop new ways to simplify how you manage claims and other administrative tasks online.

 

Next steps if you are a direct submitter:

 

Existing Availity Account

New Availity Account

Go to www.Availity.com, click LOGIN, and log in to your account.

If you are not registered for Availity, go to www.Availity.com and click the REGISTER button. Refer to this quick guide if you need help.

Under ‘My Providers’, click ‘Enrollments Center’.

Select the registration process that is appropriate to your organizational type.

Click ‘ERA Enrollment’ and follow the online instructions to complete and submit your enrollment.

Availity will send you follow-up emails with your login credentials and guidance for your next steps.

After submitting you’ll be notified by e-mail that enrollment is complete and start receiving 835’s through Availity. Please allow 5-10 business days for processing.

At this point you’ll be able to use all of the Availity benefits such as Claim Status, Eligibility, and now, EDI.

 

 

Key factors:

  • You will be able to manage changes or new registrations for the electronic remittance advice (835) through your Availity Portal account beginning June 1, 2018. We encourage you to register with Availity to initiate the change to the Availity EDI Gateway.
  • Together with Availity, we are committed to transparency with this change, and will emphasize the continuity of quality service to our trading partners.

 

We look forward to delivering a smooth transition to Availity for our EDI services. If you have any questions, please contact the E-Solutions service desk at 800-470-9630 or Availity at 800-AVAILITY (282-4548).

AdministrativeCommercialJune 19, 2018

Misrouted protected health information (PHI)

As a reminder, providers and facilities are required to review all member information received from Anthem to help ensure no misrouted PHI is included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or e-mail. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem Provider Services to report receipt of misrouted PHI.

AdministrativeCommercialJune 22, 2018

Grievance and appeal update

We’d like to remind you of the criteria for submitting an expedited appeal/grievance as well as the process to begin a standard or expedited appeal/grievance.

 

Expedited Appeals

As outlined in your Provider Manual, expedited appeals/grievances must meet certain criteria. An expedited appeal is available if services have not been provided and the timeframe of a standard appeal review could:

 

  • seriously jeopardize the covered individual’s life or health;
  • jeopardize the covered individual’s ability to regain maximum function; or if
  • in the opinion of a health care professional with knowledge of the member’s medical condition, subject the covered individual to severe pain that cannot be adequately managed without the health care service or treatment being requested.

 

We will respond to qualifying expedited appeals within 72 hours of receiving the request. 

 

Expedited appeals/grievances should not be mailed. Please fax your request with a letter of intent and supporting documentation to 855-321-3642.

(Please note that the appeals toll-free telephone number, 855-365-0953, should only be used for Connecticut fully-insured members or State of Connecticut members. Please be sure to check the member’s group information before calling this telephone number. Please also be aware that supporting documentation is needed to begin any request.

 

Please note: For administrative services only (ASO) members, call the service telephone number listed on the member’s identification card to inquire how to begin an expedited appeal/grievance, or see how to request the appeal/grievance via fax below. If you would like to begin an expedited request please be sure the request meets the expedited criteria.

 

Standard Appeals

If your situation does not meet the expedited process and you would like to begin a standard appeal/grievance, mail the request to:

 

Anthem Blue Cross and Blue Shield

PO Box 1038

North Haven CT 06473-4201

 

If you have questions, please refer to your Provider Manual which can be found on anthem.com.

AdministrativeCommercialJune 19, 2018

Member identification cards streamlined

Beginning July 1, 2018, we will introduce a streamlined member identification (ID) card to help reduce confusion about member cost share. The updated member ID card will maintain the current style, but specific cost share information (such as copays or coinsurance) will be removed from the card.

 

Providers can access Availity and the electronic data interchange (EDI) to verify member benefits and obtain the most up-to-date cost share information for a member’s plan. If a member presents an older ID card with outdated benefits at the provider office, it can create confusion about member cost share.

 

As the streamlined ID card is adopted, it will help reduce misunderstandings around cost share. Additionally, members will be encouraged to learn more about their benefits through our digital and online tools, and can retain their card for as long as they remain in the same product plan, regardless of changes to cost share information.

 

As a reminder, members can now view, download, email, and fax an electronic version of their member ID card using the Anthem Anywhere mobile app. Electronic ID cards will also be updated as described above.

 

Please note, this update does not apply to National Accounts, Federal Employee Program® (FEP®), Medicaid or Medicare plans.

 

For questions, please contact the provider service number on the back of the member’s ID card.

 

AdministrativeCommercialJune 19, 2018

Sign-up today for Network eUPDATE – it’s free!

Connecting with Anthem and staying informed is easy, faster and convenient with our Network eUPDATEs. Network eUPDATE is our web tool for sharing vital information with you. It features short topic summaries on late breaking news that impacts providers: 

 

  • Important website updates
  • System changes
  • Medical policy updates
  • Claims and billing updates

 

……and much more

 

Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you can submit as many e-mail addresses as you like.

 

AdministrativeCommercialJune 19, 2018

Receive direct deposit of patient payments with Healthcare Bill Payments

Beginning July 1, 2018, many Anthem members will be able to make payments to providers for their out-of-pocket expenses with Healthcare Bill Payments, a new feature via the member portal at anthem.com. Now, your patients can quickly and easily pay you online as soon as their claim information is available.

 

We have engaged InstaMed®, a healthcare payments network, to offer Healthcare Bill Payments. InstaMed is a payment card industry (PCI) level one service provider and certified at the highest levels for both healthcare and payment processing.

 

Providers registered with InstaMed will conveniently receive patient payments by direct deposit into their bank account without ever mailing a patient bill or making a phone call. Plus, patients enjoy a simple, convenient payment option.

 

Registration for Healthcare Bill Payments is simple – you can get started today. Here’s what you’ll need:

 

  • Email address
  • Tax ID number for your organization
  • Bank account information for direct deposit

 

If you are not registered, these payments are mailed to you as prepaid Mastercard® payments.

 

For more information about Healthcare Bill Payments:

 

 

This feature does not apply to our Medicare and Medicaid plans, but may be implemented in the future.

AdministrativeCommercialJune 22, 2018

Anthem PPACA Exchange Network Consolidations

As required by the Patient Protection and Affordable Care Act, we offer the same products, programs and plans (collectively Products) directly to consumers that we offer on Access Health CT (the State of Connecticut’s health care exchange).  Members of these off-exchange Products are currently able to access, on an in-network basis, health care services rendered by providers and facilities participating in our BlueCare (HMO/POS) or Century Preferred (PPO) provider network, as applicable. 

 

Beginning January 1, 2019, all members of our off-exchange Products will be required to utilize our exchange networks to receive in-network benefits. Specifically:

 

  • Members of our small group off-exchange HMO Products must use the Pathway X HMO Exchange Network.
  • Members of our individual off-exchange HMO Products must use the Pathway X Enhanced Exchange Network.
  • Members of our small group off-exchange PPO Products must use the Pathway X PPO Exchange Network.
  • Members of our individual off-exchange PPO Products must use the Pathway X Exchange Network.

 

For dates of service on and after January 1, 2019, you must participate in the applicable exchange network(s) listed above to render health care services on an in-network basis to members of off-exchange Products. Compensation for covered health care service rendered to members of off-exchange Products will be the amounts corresponding to the applicable Pathway network(s).

 

If you do not currently participate in our exchange network(s) and wish to, you may contact your Provider Relations Representative.  

 

If you have any questions, please call the Provider Call Center at 800-922-3242. We thank you for your continued service and dedication to all our members.

AdministrativeCommercialJune 19, 2018

Claim processing update for services requiring AIM pre-service clinical review

We recently discovered that some claims for services under the following programs are processing without the required pre-service clinical review through AIM Specialty Health® (AIM®), a separate company:

 

  • Sleep management
  • Radiation oncology
  • Radiology benefit management (RBM)
  • Cardiology

 

Effective July 1, 2018, our claims systems will be updated to correct this issue. Claims for sleep management, radiation oncology, RBM, and cardiology services continue to require precertification through AIM. For a list of the codes that require pre-service clinical review visit the AIM ProviderPortal℠.

 

As a reminder, please submit pre-service clinical review requests to AIM in one of the following ways:

 

 

AdministrativeCommercialJune 19, 2018

Pre-service clinical review drug list changes effective September 1, 2018

Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our pre-service clinical review process.

 

Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health (AIM), a separate company.

 

The following clinical guidelines or medical policies will be effective September 1, 2018:

Clinical UM Guideline or Medical Policy

Drug Name

Drug Code(s)

CG-DRUG-44

Krystexxa®

J2507

CG-DRUG-89

Sublocade™

J3490, Q9991, Q9992

AdministrativeCommercialJune 19, 2018

Level of care pre-service clinical review drug list changes effective September 1, 2018

Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy level of care review process.

 

Level of care pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health (AIM), a separate company.

 

View the Clinical Site of Care (Level of Care) drug list and Clinical Site of Care (Level of Care) pre-service clinical review FAQs for more information.

Clinical UM Guideline or Medical Policy

Drug Name

Drug Code

CG-DRUG-05

Mircera®

J0888

CG-DRUG-09

CuvitruTM

J1555

CG-DRUG-16

Zarxio®

Q5101

CG-DRUG-44

Krystexxa®

J2507

CG-DRUG-61

Supprelin LA®

J9226

CG-DRUG-69

Stelara®

J3358

CG-DRUG-78

Fibryga®

J7178

CG-DRUG-78

Rebinyn®

J7195

DRUG.00027

Prialt®

J2278

DRUG.00081

Exondys 51TM

J1428

DRUG.00093

KanumaTM

J2840

DRUG.00095

OcrevusTM

J2350

AdministrativeCommercialJune 19, 2018

Verifying eligibility for expanded hospice benefits

In the April 2018 edition of Network Update, we announced an expansion of hospice benefits for local Anthem fully-insured plans to begin on June 1, 2018. The newly expanded benefits allow for disease modifying treatments to continue alongside hospice services, as well as member access to hospice services with prognoses of up to 12 months.

 

Providers should verify whether members have the expanded hospice benefit under their Anthem policy.

 

For some health plans, updated benefit information will return via an electronic eligibility and benefit inquiry on the Availity Portal or using your Electronic Data Interchange (EDI) interface as early as June 1, 2018. We anticipate that all impacted plans will return the updated language by August 1, 2018. Once updated, hospice inquiries (Service Type 45) will confirm access to the expanded hospice benefit by returning: “Life expectancy up to 12 months with disease modifying treatment allowed.”

 

Please note: From June 1, 2018 through August 1, 2018, we’ll be updating our systems to report more detailed benefit language. During that timeframe, it may be necessary to contact the Provider Service number on the back of the member’s ID card to confirm if the member’s plan includes the expanded hospice benefit.  

 

As a reminder, the following plans include the expanded hospice benefits beginning June 1, 2018: commercial fully-insured group and individual plans. The following plans do not include expanded hospice benefits: self-insured plans, Medicare, Medicaid, and FEP.

AdministrativeCommercialJune 19, 2018

Durable medical equipment miscellaneous code E1399 reminder

We continually evaluate coding and billing patterns, and recently identified trends related to the use of code E1399 — DME, miscellaneous. When an appropriate code exists for DME equipment or supply, the more specific code should be used.

 

Inappropriate use of code E1399 often includes, but is not limited to the following:

 

  • Gait trainers (E8001/E8002)
  • Shower chairs (E0240)
  • Standing frames (E0641)
  • Hospital beds (E0250-E0373)
  • Stand assist lifts (E0635)

 

To help ensure proper use of E1399, we conduct post-payment reviews of code E1399.  If a more appropriate code should have been used, we may recoup overpayments accordingly.

 

We continue to require prior authorization for the use of miscellaneous code E1399. If a prior authorization is approved but the claim is submitted with the incorrect code E1399, the claim may be denied and a corrected claim will need to be resubmitted with the appropriate HCPCS code.

Behavioral HealthCommercialJune 22, 2018

MCG Care Guidelines adopted for behavioral health services

Effective with dates of service on and after October 31, 2018, we will begin using MCG Care Guidelines 22nd edition behavioral health guidelines for the review of behavioral health services. This represents a change from the behavioral health medical policies and clinical guidelines currently used. 

 

Please note that the following behavioral health medical policies and clinical guidelines (BEH) will be retained at this time:

  • 00002 - Transcranial Magnetic Stimulation
  • 00004 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
  • CG-BEH-01 - Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
  • CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
  • CG-BEH-14 - Intensive In-Home Behavioral Health Services

 

We may continue to use additional medical policies and clinical guidelines to supplement MCG Care Guidelines.

 

View our medical policies and clinical guidelines and view Customizations to MCG Care Guidelines 22nd edition.

 

This change impacts our Commercial health plans.

 

Providers should continue to call the phone number indicated on the back of the member’s ID card to request prior authorization review or for additional questions regarding behavioral health benefits.

Behavioral HealthCommercialJune 19, 2018

Outpatient behavioral health therapy visits

Please note that we no longer manage traditional behavioral health outpatient therapy for all fully-insured products, including our health insurance exchange products. Many of our self-funded groups have also removed review of the traditional outpatient therapy visits; however, some groups continue to require a review after a certain number of pass-through visits.

 

Please be certain to verify benefits for new patients to help ensure you are aware of any requirements. Partial hospitalization, intensive outpatient, applied behavior analysis, trans-cranial magnetic stimulation (TMS) services continue to require prior authorization from the first visit.

Behavioral HealthCommercialJune 22, 2018

Crisis stabilization

 

We are now providing benefits for crisis stabilization services for commercially-insured members in Connecticut. The Children’s Center of Hamden is providing these services.

 

Crisis stabilization services are direct mental health care services to non-hospitalized individuals experiencing an acute crisis of a psychiatric nature that may jeopardize their current community living situation. The goals are to avert hospitalization or re-hospitalization; stabilize individuals in psychiatric crisis; and mobilize the resources of the community support system, family members, and others for ongoing maintenance, rehabilitation, and recovery. 

 

If you are treating an Anthem member who may be appropriate for this service or if you have any questions, please call 800-934-0331.

 

Medical Policy & Clinical GuidelinesCommercialJune 22, 2018

Medical policy and clinical guidelines updates are available on anthem.com

The following new and revised medical policies and clinical guidelines were endorsed at the March 22, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > Select a state > 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 March 29, 2018

(The following policies were revised to expand medical necessity indications or criteria.)

 

DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors

GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility

SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke

 

New medical policy effective March 29, 2018

(The policy below is new and determined to not have significant change.)

 

MED.00120 - Voretigene neparvovec (Luxturna™)

 

Revised medical policies effective April 25, 2018   

(The following policies were revised to expand medical necessity indications or criteria.)

 

DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting

RAD.00029 - CT Colonography (Virtual Colonoscopy) for Colorectal Cancer

SURG.00121 - Transcatheter Heart Valve Procedures

 

Revised medical policies effective April 25, 2018      

(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

 

ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck

DME.00032 - Automated External Defibrillators for Home Use

DRUG.00086 - Mecasermin (Increlex®)

DRUG.00108 - Edaravone (Radicava®)

GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease

GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

MED.00007 - Prolotherapy for Joint and Ligamentous Conditions

MED.00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State

MED.00059 - Idiopathic Environmental Illness (IEI)

MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)

RAD.00012 - Ultrasound for the Evaluation of Paranasal Sinuses

RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care

RAD.00044 - Magnetic Resonance Neurography

RAD.00052 - Positional MRI

REHAB.00003 - Hippotherapy

SURG.00033 - Cardioverter Defibrillators

SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons

SURG.00045 - Extracorporeal Shock Wave Therapy for Orthopedic Conditions

SURG.00048 - Panniculectomy and Abdominoplasty

SURG.00053 - Unicondylar Interpositional Spacer

SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence

SURG.00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses

SURG.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

SURG.00066 - Percutaneous Neurolysis for Chronic Neck and Back Pain

SURG.00070 - Photocoagulation of Macular Drusen

SURG.00073 - Epiduroscopy

SURG.00079 - Nasal Valve Suspension

SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches

SURG.00100 - Cryoablation for Plantar Fasciitis and Plantar Fibroma

SURG.00111 - Axial Lumbar Interbody Fusion

SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

SURG.00150 - Leadless Pacemaker

TRANS.00008 - Liver Transplantation

TRANS.00009 - Lung and Lobar Transplantation

TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation

TRANS.00013 - Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation

TRANS.00026 - Heart/Lung Transplantation

TRANS.00033 - Heart Transplantation

 

Archived medical policy effective June 22, 2018

(This policy is now an Anthem Clinical Guideline.)

 

DRUG.00092 - Buprenorphine Implant (Probuphine®)

 

Archived medical policies effective June 28, 2018

(These polices are now Anthem Clinical Guidelines.)

 

BEH-00004 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

DRUG.00028 - Intravitreal Treatment for Retinal Vascular Conditions

DRUG.00032 - Intravitreal Corticosteroid Implants

DRUG.00072 - Alpha-1 Proteinase Inhibitor Therapy

DRUG.00101 - Sarilumab (Kevzara®)

LAB.00020 - Skin Nerve Fiber Density Testing

MED.00076 - Inhaled Nitric Oxide

RAD.00030 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

SURG.00081 - Total Ankle Replacement

SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation

SURG.00110 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions

THER-RAD.00003 - Intravascular Brachytherapy (Coronary and Non-Coronary

 

Archived medical policy effective October 31, 2018

(This policy is now an MCG Behavioral Health Clinical Guideline.) 

 

BEH.00001 - Opioid Antagonists under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification

 

Revised medical policies effective September 1, 2018

(The following policies listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)

 

DRUG.00003 - Chelation Therapy

OR.PR.00003 - Microprocessor Controlled Lower Limb Prostheses

SURG.00037 - Treatment of Varicose Veins (Lower Extremity)

SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

New medical policy effective September 1, 2018

(The policy below is new and may result in services previously covered now being considered either not medically necessary and/or investigational)

 

SURG.00151 - Balloon Dilation of Eustachian Tubes

 

Revised clinical guidelines effective April 25, 2018   

(The following guidelines were revised and had no significant changes to the position or criteria.)

 

CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder

CG-BEH-03 - Psychiatric Disorder Treatment

CG-BEH-07 - Psychological Testing

CG-DRUG-27 - Clostridial Collagenase Histolyticum Injection

CG-DRUG-57 - Idursulfase (Elaprase®)

CG-MED-55 - Level of Care: Advanced Radiologic Imaging

CG-MED-68 - Therapeutic Apheresis

CG-SURG-09 - Temporomandibular Disorders

CG-SURG-27 - Sex Reassignment Surgery

CG-TRANS-02 - Kidney Transplantation

 

New and adopted clinical guidelines effective June 22, 2018

(The following guidelines were previously medical policies and have been adopted. No significant changes were made.)

 

CG-DRUG-89 - Implantable and Extended-Release Buprenorphine-Containing Products  

CG-DRUG-92 - Alpha-1 Proteinase Inhibitor Therapy

 

New and adopted clinical guidelines effective June 28, 2018

(The following guidelines were previously medical policies and have been adopted. No significant changes were made.)

 

CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions

CG-DRUG-91 - Intravitreal Corticosteroid Implants

CG-DRUG-93 - Sarilumab (Kevzara®)

CG-LAB-13 - Skin Nerve Fiber Density Testing

CG-MED-69 - Inhaled Nitric Oxide

CG-MED-70 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

CG-SURG 73 - Self-Expanding Absorptive Sinus Ostial Dilation

CG-SURG-74 - Total Ankle Replacement

CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions

CG-THER-RAD.07 - Intravascular Brachytherapy (Coronary and Non-Coronary

 

Revised clinical guidelines effective September 1, 2018

(The following guidelines might result in services that were previously covered now being considered not medically necessary.)

 

CG-DME-06 - Pneumatic Compression Devices for Lymphedema

CG-REHAB-04 - Physical Therapy

CG-REHAB-05 - Occupational Therapy

 

Adopted clinical guideline effective September 1, 2018

(The following guideline was adopted and might result in services that were previously covered now being considered not medically necessary.)

 

CG-DRUG-44 - Pegloticase (Krystexxa®)

 

Archived clinical guidelines effective October 31, 2018

(These guidelines are now MCG Behavioral Health Clinical Guidelines.) 

 

CG-BEH-03 - Psychiatric Disorder Treatment

CG-BEH-04 - Substance-Related and Addictive Disorder Treatment

CG-BEH-05 - Eating and Feeding Disorder Treatment

CG-BEH-07 - Psychological Testing

CG-MED-23 - Home Health

Reimbursement PoliciesCommercialJune 22, 2018

Durable Medical Equipment professional reimbursement policy reminders

In the April 2016 edition of Network Update, we shared details about the professional reimbursement policy, Durable Medical Equipment. Following are some important reminders about this policy.

 

  • Certain DME is not routinely purchased up-front; rent-to-purchase durable medical equipment (DME) is eligible for rental reimbursement up to the purchase price or 10 months rental, whichever comes first. We are receiving claims billed with up-front purchases and we are denying those claims because they must be billed as rent-to-purchase. If you receive such a denial, please do not request a medical necessity review as that was not the reason for the denial. Instead, please bill claims for these services correctly as rent-to-purchase.  

 

  • For dates of service on or after July 1, 2016, the following HCPCS codes for sleep apnea equipment are only eligible for reimbursement when reported as rented items, and should not be reported with DME purchase modifiers NR (new when rented (use modifier NR when DME that was new at the time of rental is subsequently purchased)), NU (new equipment), or UE (used durable medical equipment): 

 

  • E0470 (respiratory assist device, bi-level pressure capability, without backup rate feature)
  • E0471 (respiratory assist device, bi-level pressure capability, with back-up rate feature)
  • E0561 (humidifier, non-heated, used with positive airway pressure device)
  • E0562 (humidifier, heated, used with positive airway pressure device)
  • E0601 (continuous positive airway pressure (CPAP) device)

 

For more information about the Durable Medical Equipment reimbursement policy, visit the professional reimbursement policy webpage at anthem.com.

Reimbursement PoliciesCommercialJune 19, 2018

Diagnosis-Related Group Newborn Inpatient Stays facility reimbursement policy update

Effective for dates of service on and after September 1, 2018, we will implement the new facility reimbursement policy, Diagnosis-Related Group (DRG) Newborn Inpatient Stays.  

 

The following details provide important information about this policy:

 

  • All newborn inpatient stays must include sufficient documentation or prior authorization to support an admission to a level of care area beyond the newborn nursery, such as the neonatal intensive care unit (NICU), or for the higher level of care associated with more complex newborn DRG.
  • Newborn claims submitted for a higher level of care DRG that do not include the appropriate documentation, or those submitted with only newborn care revenue codes (170 and 171) and no prior authorization will be automatically processed based on the normal newborn rate. 
  • Current prior authorization guidelines for normal newborn and higher level of care newborn inpatient stays apply.

 

We have created a new remark code to help provide additional detail in the above mentioned claim scenarios. The explanation, “Claim did not meet criteria for higher DRG payment. Level of care adjustment has been made. Claim paid at Normal Newborn DRG.” will appear on the provider remit when a claim is submitted with a higher level of care newborn DRG code and the required documentation or prior authorization is not on file. Providers may appeal decisions related to the DRG Newborn Inpatient Stays policy by following their normal appeal process and submitting the appropriate supporting clinical documentation.

 

For more information about DRG Newborn Inpatient Stays reimbursement policy, visit the CT facility reimbursement policy webpage ME facility reimbursement policy webpage NH facility reimbursement policy webpage at anthem.com.

Reimbursement PoliciesCommercialJune 19, 2018

Cervical Cancer Screening using Cytology and Human Papillomavirus Testing (CG-MED-43) not implemented

 

In the October 2017 edition of the Network Update, we announced a new coverage guideline, Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing (CG-MED-53) to be effective January 1, 2018. Please be advised that CG-MED-53 was not implemented. 

Reimbursement PoliciesCommercialJune 19, 2018

Review of reimbursement policies – professional

The following professional reimbursement policies were reviewed and may have minor language changes; however, the changes do not cause significant changes to the policies’ position or criteria:

 

  • Documentation Reporting Guidelines for Consultations
  • Duplicate Reporting of Diagnostic Services
  • Frequency Editing
  • Overhead Expense for Office Based Surgery and Diagnostic Testing
  • Sleep Studies and Related Bundled Services & Supplies
  • Unit Frequency Maximums for Drugs and Biologic Substances

 

Reimbursement PoliciesCommercialJune 22, 2018

Update to Use of a Non-Participating Provider Advance Patient Notice Policy

Participating providers and facilities are asked to review the updated Use of a Non-participating Provider Advance Patient Notice Policy. Effective as of June 1, 2018, we have updated the policy to clarify its scope and purpose.

Products & ProgramsCommercialJune 19, 2018

AIM Musculoskeletal Program Clinical Appropriateness Guidelines updates

Beginning with dates of service on and after July 1, 2018, the following updates will apply to AIM Musculoskeletal Program Clinical Appropriateness Guidelines.

 

Spine surgery guideline: 

  • Cervical decompression with or without fusion:
    • Added osteotomy and corpectomy definitions
    • Clarified implant/instrumentation failure
  • Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis):
    • Added osteotomy and corpectomy definitions
  • Spinal stenosis:
    • Removed bilateral or wide decompression

 

Interventional pain management guideline: 

  • Epidural injection procedures and diagnostic selective nerve root blocks:
    • Added pre-service clinical review exemption for CPT codes 62320 and 62322 when used for post-procedural pain with certain ICD-10-CM diagnoses
  • Repeat therapeutic epidural steroid injections, clarified initial injection as therapeutic:
    • Clarified injection sessions for procedural requirements
  • Paravertebral facet injection/nerve block/neurolysis:
    • Increased procedural limitation for diagnostic medial branch blocks
    • Increased procedural limitation for therapeutic intra-articular facet joint injections and clarified requirement for conservative treatment between injections
  • Sacroiliac joint injections:
    • Added HCPCS code G0260

 

Ordering and servicing providers may submit pre-service clinical review requests to AIM in one of the following ways:

 

 

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 guidelines here.

 

Products & ProgramsCommercialJune 19, 2018

Individualized Care Program to support palliative care for commercial members

Beginning June 1, 2018, we will offer an Individualized Care Program to our fully-insured commercial members to provide palliative care support for members with advanced illness in the last 12 months of life.  

 

This program does not replace the care of PCPs and specialists, but provides an extra layer of support with an interdisciplinary team that includes palliative care physicians, palliative care nurse practitioners, registered nurses, social workers, chaplains and patient care coordinators.

 

Specific palliative care services include:

 

  • Comprehensive assessments including symptoms, spiritual and psychosocial needs
  • Expert symptom management
  • Supporting patients in defining their goals, values and preferences and in advance care planning
  • Encouraging patients to execute advance directives
  • 24/7 access to urgent clinical support from a palliative care team member
  • Securing needed resources
  • Education on palliative services and hospice care services

 

An initial telephonic outreach to identified members will be made by a palliative care professional to introduce our Individualized Care Program and to determine the appropriate level of palliative services in one of the following three models:

 

  1. Telehealth services and support at routine intervals to members by palliative trained providers
  2. Home based visits by a palliative care nurse practitioner, supported by an interdisciplinary team of palliative providers for members with a high symptom burden, increased risk of hospitalization, or other complex issues. The home based visits will be offered through a collaboration with Aspire Health (available in certain geographic areas).
  3. Clinic based services offered through a collaboration with Aspire Health. Aspire’s palliative care team will be embedded within the outpatient clinic/practice of the member’s medical oncologist to provide services to targeted patients (available in certain geographic areas).

 

Aspire Health already provides services for members with advanced illness enrolled in our Medicare and Medicaid health plans and has demonstrated improvement in quality and cost of care savings.

 

If you are an Anthem contracted network provider, an Aspire Health palliative physician may reach out to your practice to introduce themselves in order to establish a physician to physician relationship. They may also discuss developing an individualized mechanism by which to share information regarding patients that have been identified for palliative care services. Aspire will provide clinical updates to your practice on a regular basis to facilitate the best possible co-management of your patient.

 

If you have questions about our Individualized Care Program, please email IndividualizedCareProgram-PalliativeCare@anthem.com.

 

Products & ProgramsCommercialJune 22, 2018

Anthem Quality-In-Sights 2017 results available in late July 2018

For primary care physicians participating in the 2017 Anthem Quality-in-Sights (AQI) Primary Care Quality Incentive Program, please be advised that the results from the 2017 measurement period will be available on our Provider Online Interactive Tool (POIT) portal at the end of July 2018. 

 

The POIT portal is accessible through Availity. Log onto Availity.com > My Payer Portal > Anthem Provider Portal > Answers@Anthem > Provider Online Interactive Tool (POIT) > Rewards & Recognition at the end of July 2018 to access your scorecard.

PharmacyCommercialJune 19, 2018

Prior authorization requests for prescription medications accepted online

 

As a reminder, we accept electronic prior authorization requests for prescription drugs for commercial health plans. This feature reduces processing time and helps determine coverage quicker. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

 

Electronic prior authorization (ePA) offers many benefits to providers:

 

  • More efficient review process
  • Ability to identify if a prior authorization is required
  • Able to see consolidated view of ePA submissions in real time
  • Faster turnaround times
  • A renewal program that allows for improved continuity of care for members with maintenance medications. Prior authorizations are preloaded for the provider before the expiration date.

 

Providers can submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

 

For questions, please contact the provider service number on the back of the member ID card.

PharmacyCommercialJune 22, 2018

Pharmacy information available on anthem.com

Visit the applicable websites noted below for more information on the following:  

 

  • copayment/coinsurance requirements and their applicable drug classes
  • drug lists and changes
  • prior authorization criteria
  • procedures for generic substitution
  • therapeutic interchange
  • step therapy or other management methods subject to prescribing decisions
  • other requirements, restrictions or limitations that apply to certain drugs

 

To locate the commercial drug list, go to anthem.com > Customer Support > Connecticut > Download forms > Anthem Blue Cross and Blue Shield Drug Lists.

 

To locate the Marketplace Select Formulary and pharmacy information for health plans offered on the Exchange Marketplace, go to anthem.com > Customer Support  > Connecticut > Download forms > Connecticut Select Drug List.

 

The commercial and marketplace drug lists are reviewed and updates are posted to the website quarterly (the first of the month for January, April, July and October).  

 

Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. This drug list is also reviewed and updated regularly as needed.

State & FederalMedicare AdvantageJune 19, 2018

Cologuard covered for Medicare Advantage members

Please note, this notice is only applicable to Medicare Advantage members: Cologuard, the at-home colorectal cancer screening, is covered at 100 percent for Anthem Medicare Advantage individual and group-sponsored members. Members will not incur an out-of-pocket cost for the screening and no prior authorization is required.

 

71411MUPENMUB 03/27/2018

State & FederalMedicare AdvantageJune 19, 2018

Peer-to-peer process can help clarify clinical record

he Medicare peer-to-peer process facilitates a conversation between a provider and an Anthem medical director. The peer-to-process should be used to explain or clarify something that a clinical record cannot convey. To learn how to initiate a peer-to-peer conversation, please see Important Medicare Advantage Updates at anthem.com/medicareprovider

State & FederalMedicare AdvantageJune 19, 2018

MA home health network to be delegated to myNEXUS

We want to thank our PCPs and hospitals for their coordination of home health care for our members. We want to alert you to important changes to our home health provider network for most of our Medicare Advantage members. We will delegate our provider network for home health care services for most of our Medicare Advantage members to myNEXUS August 1, 2018. 

Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.

 

State & FederalMedicare AdvantageJune 19, 2018

Medication adherence incentive offered to EPHC providers

Medication non-adherence increases mortality and costs the healthcare system billions of dollars per year. We are collaborating with physicians engaged in our Enhanced Personal Health Care (EPHC) programs to promote adherence by increasing 90-day supply prescriptions. Patients who receive 90-day supplies are more likely to be adherent, and our Medicare Advantage plans allow 90-day supplies to be filled for chronic medications at any retail pharmacy. Beginning in July, EPHC providers will receive a monthly report that identifies Medicare members eligible for a 90-day supply.  Please evaluate that member list and discuss the benefits of a 90-day supply with your patients.

State & FederalMedicare AdvantageJune 19, 2018

Motion Picture Industry Pension and Health Plans Offers Medicare Advantage Option

Effective July 1, 2018, Anthem will be a Medicare Advantage (MA) plan option for Motion Picture Industry Health and Pension Plans (MPI).  We will provide medical benefits for MPI retirees through a Local Preferred Provider Organization (LPPO) product.  The MA plan offers the same hospital and medical benefits that Medicare covers. In addition, MPI retirees will pay the same cost share for both in-network and out-of-network services. The MA plan also covers additional benefits that Medicare does not such as hearing, acupuncture, LiveHealth Online and SilverSneakers.

 

MPI retirees will have a customized identification card that includes the MPI logo. The prefix on their cards will be MBL.

Providers will follow their normal claim filing procedures for MPI member claims.   

 

State & FederalMedicare AdvantageJune 22, 2018

Connecticut Teachers’ Retirement Board Offers Anthem Medicare Advantage Option

Effective July 1, 2018, Anthem will be a Medicare Advantage (MA) plan option for Connecticut Teachers’ Retirement Board (TRB).  We will provide medical benefits for TRB retirees through our Local Preferred Provider Organization (LPPO) product.  The MA plan offers the same hospital and medical benefits that Medicare covers. The MA plan also covers additional benefits that Medicare does not such as LiveHealth Online and SilverSneakers. 

 

TRB retirees will have a customized identification card that includes TRB’s logo.  The prefix on their cards will be ZDX. Providers will follow their normal claim filing procedures for MPI member claims.

  

State & FederalMedicare AdvantageJune 19, 2018

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