 Provider News ConnecticutJune 2019 Anthem Connecticut Provider Newsletter Contents Medical Policy & Clinical Guidelines | Commercial | May 31, 2019 Coding UpdatesMedical Policy & Clinical Guidelines | Commercial | May 31, 2019 Coding Updates
This quarter, anthem.com will release more exciting enhancements to the public provider site. The next wave of changes includes a new Behavioral Health page that will provide easy and clear access to content and resources, including newsletters, collaboration documents, and other relevant information for providers. The images below illustrates the new Behavioral Health page.
We will continue to provide updates as we move forward with migrating content to the new provider pages. Our Find a Doctor tool provides Anthem members with the ability to search for in-network providers using the member portal at anthem.com. Find a Doctor currently offers multiple sorting options, such as sorting providers based on distance or name.
In May 2019, we added a new sorting option to Find a Doctor. The new sorting option is called “Personalized Match” and is based on algorithms which use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures. These member and provider features combine to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius are displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius. Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.
Please note, the sorting option “Personalized Match” has been available on Care and Cost Finder since November 12, 2018.
Additional information about Personalized Match:
- Provider factors will be updated on a quarterly basis.
- Providers may review a copy of the sorting methodology here.
- If you have general questions about this sorting option in Find a Doctor and the Care and Cost Finder tool, please contact Provider Service.
- If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.
We will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. As we prepare for potential regulatory proposed standards for electronic attachments, we will be implementing what is called the X12 275 5010 version of electronic attachments transactions for claims. Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reduced processing time overall.
Anthem and Availity will be piloting Electronic Data Interchange (EDI) batch electronic attachments with previously selected providers. Both solicited and unsolicited attachments will be included in our pilots.
Solicited attachment
Provider sends a claim and the payer determines there is insufficient information to process the claim. Payer then sends the provider a request for additional information (currently via letter). Provider can then send the solicited attachment transaction with the documentation requested to process the claim.
Unsolicited attachment
When the provider knows that the payer requires additional information to process the claim, the provider then sends the X12 837 claim with the “Paper Work Included” (PWK) segment tracking number. Next, the provider sends the X12 275 attachment transaction with the additional information and includes the tracking number that was sent on the claim for matching purposes.
What you can do now
We encourage you to start having conversations with your Clearinghouse and/or Electronic Healthcare Records (EHR) vendor to determine their ability to set up the X12 275 attachment transaction capabilities.
Look for more information about the general availability of this time-saving option later this summer and details on how to work with Anthem and Availity to send your attachments via electronic batch. Beginning June 17, 2019, a new option will be available for Connecticut providers to check the status of an Anthem claim on the Availity Portal. The link under the Claims & Payments menu is titled ‘Claim Status and Remittance Inquiry’. The ability to check on a claim using the legacy claim status inquiry tool will no longer be available as of that date.
You may also use the 'Go To' menu on the patient eligibility and benefit detail page to navigate seamlessly to the new look.
The new claim status look includes color coded patient ID cards and easy to read claim detail.
Secure Messaging Changes
A new Actions menu on the updated Claim Status page will be used to access the Secure Provider Messaging tool. The link ‘Do you have a question about this claim?‘ will no longer be available with the new claim screen. You can also use the 'Actions' menu to edit or print the claim screen.
For more information on the changes, a Claim Status training webinar is coming mid-month. Access the training Enroll link by logging in to the Availity Portal and selecting Help & Training | Get Trained. To help ensure compliance with the coding and billing of services submitted with a diagnosis of sepsis, we review clinical information, including lab results, treatment and medical management, in the medical records submitted. In order to conduct the review accurately and consistently, our review process for sepsis diagnoses applies coding and documentation guidelines, in addition to the updated and most recent sepsis 3 clinical criteria, published in JAMA February 2016. Clinicians and facilities should apply the sepsis 3 criteria when determining at discharge if their patient’s clinical course supports the coding and billing of a sepsis diagnosis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the sepsis 3 definition and criteria. Continuing our 2019 CRA updates, we request your assistance with respect to our CRA reporting processes. As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy. This month we’d like to focus on the Retrospective approach, and the request to our providers.
Retrospective Program:
- Focus is on medical chart collection
- Medical record documentation supports provisions of ACA that require Anthem to collect and report diagnosis code data for ACA members
- Medical chart collection will start soon (separated in three different time periods)
- Period 1 (June 2019)
- Period 2 (November 2019)
- Period 3 (January 2020)
Anthem’s medical chart collection is in compliance with the ACA provision to collect and report diagnosis code data for ACA members
Electronic options for chart collections:
Submitting medical charts to payers can be extremely burdensome and time consuming for your staff. Utilizing an electronic option can alleviate the constraints on both staff resources and time.
- Remote/Direct Anthem Access
- The most efficient option is to allow Anthem’s medical coder team to have direct connection access to your EMR system for Anthem to retrieve member records.
- Allows for no vendor interventions and fewer handoffs of the records.
To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI.
Benefits of providing EMR direct connection access
- Medical records staff resources minimally contacted for charts requested
- Depending on EMR system, requests may also be handled electronically through “push” notifications
- Medical records staff will release only those records requested into EMR queue for which we have access
- Cost savings - - less administrative impact on staff and no paper copying costs
- Better privacy/security measures - - no need to save medical record to desktop and then copy/save before transmittal
- EMR Interoperability. Options are in place for the following EMR systems:
- Allscripts (Opt in –signature required. Need to work directly with the CRA representative for your region)
- NextGen (Opt out – auto-enrolled)
- Athenahealth (Opt out – auto enrolled)
- MEDENT (Opt in – signature required. Need to work directly with the CRA representative for your region)
- Inovalon virtual visit or onsite
- Inovalon will work directly with your office to utilize electronic connectivity for a virtual visit, or they will have their staff go into the office for medical record retrieval based on a scheduled time that is convenient.
- Secure FTP
- Set up directly with our vendors as a temporary secure FTP to transfer medical records.
If you are interested in any of these electronic options, or would like to grant our Anthem medical coders with direct access to your EMR, please contact our CRA Representative Alicia.Estrada@anthem.com.
Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests that will begin soon.
Obesity is a complex, multifaceted, chronic disease. Environmental, metabolic, behavioral, and genetic factors can all affect obesity. A study by the Robert Wood Johnson Foundation found that obesity contributes to nearly 1 in 5 deaths in the United States.1 The ranges are determined by using the “body mass index” (BMI) since BMI provides the most useful population-level measure of overweight and obesity.1 Careful monitoring of BMI will help health care providers identify adults who are at risk and provide focused advice and services to help them reach and maintain a healthier weight. It also ties to NCQA ratings and is a HEDIS measure.
What is the HEDIS measure?
The percentage of members 18 – 74 years of age who had an outpatient visit and whose body mass index was documented during the measurement year or the year prior to the measurement year. To get HEDIS credit a patient’s medical record needs to include height, weight, calculated BMI, and date of service.2 BMI documentation is commonly overlooked, which prevents the documentation from meeting criteria for this measure.
Continued management and diverse pathways to care are essential in controlling BMI. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value Based Services, and other pay-for-performance models.3
Tips for talking with patients4
- Reinforce importance of lifestyle changes such as being active or making dietary choices that lead to weight loss and improve overall health
- Encourage patient to set goals regarding his or her weight
- Discuss weight loss medications for people with health problems related to excess weight
- Consider bariatric surgery for patients who:
- Continue to have severe obesity (BMI greater than 40 kg) after trying lifestyle changes to lose weight
- Have a BMI greater than 35 kg and have one or more chronic conditions linked to obesity
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 email. 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 and 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 Service to report receipt of misrouted PHI. 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 > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Practice Guidelines. The following new and revised medical policies were endorsed at the March 21, 2019 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 March 28, 2019
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00053 - Carfilzomib (Kyprolis®)
- DRUG.00082 - Daratumumab (DARZALEX®)
- DRUG.00088 - Atezolizumab (Tecentriq®)
Revised medical policies effective April 24, 2019
(The following policies were revised to expand medical necessity indications or criteria.)
- GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
- SURG.00121 - Transcatheter Heart Valve Procedures
Revised medical policies effective April 24, 2019
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
- DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting
- DME.00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
- DME.00032 - Automatic External Defibrillators for Home Use
- DRUG.00076 - Blinatumomab (Blincyto®)
- DRUG.00107 - Avelumab (Bavencio®)
- DRUG.00109 - Durvalumab (Imfinzi®)
- GENE.00001 - Genetic Testing for Cancer Susceptibility
- GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00009 - Gene-Based Tests for Screening, Detection or Management of Prostate Cancer
- GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
- GENE.00023 - Gene Expression Profiling for Uveal Melanoma
- GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing
- GENE.00038 - Genetic Testing for Statin-Induced Myopathy
- LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00011 - Analysis of Proteomic Patterns
- LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
- LAB.00025 - Topographic Genotyping
- MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
- MED.00011 - Sensory Stimulation for Brain Injured Individuals in Coma or Vegetative State
- MED.00024 - Adoptive Immunotherapy and Cellular Therapy
- MED.00053 - Noninvasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
- MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00059 - Idiopathic Environmental Illness (IEI)
- MED.00077 - In Vivo Analysis of Gastrointestinal Lesions
- MED.00087 - Imaging Techniques for Screening and Identification of Cervical Cancer
- MED.00102 - Ultrafiltration in Decompensated Heart Failure
- MED.00104 - Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
- MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00111 - Intracardiac Ischemia Monitoring
- MED.00112 - Autonomic Testing
- MED.00118 - Continuous Monitoring of Intraocular Pressure
- MED.00120 - Voretigene neparvovec-rzyl (Luxturna®)
- MED.00125 - Biofeedback and Neurofeedback
- OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
- RAD.00001 - Computed Tomography of Detect Coronary Artery Calcification
- RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
- RAD.00040 - PET Scanning using Gamma Cameras
- RAD.00044 - Magnetic Resonance Neurography
- RAD.00052 - Positional MRI
- RAD.00054 - MRI of the Bone Marrow
- RAD.00059 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord
- SURG.00016 - Stereotactic Radiofrequency Pallidotomy
- SURG.00022 - Lung Volume Reduction Surgery
- SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00045 - Extracorporeal Shock Wave Therapy for Orthopedic Conditions
- SURG.00053 - Unicondylar Interpositional Spacer
- SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
- SURG.00061 - Presbyoia and Astigmastism-Correcting Intraocular Lenses
- SURG.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
- SURG.00070 - Photocoagulation of Macular Drusen
- SURG.00072 - Lysis of Epidural Adhesions
- SURG.00075 - Intervertebral Stabilization Devices
- SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation
- SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
- SURG.00107 - Prostate Saturation Biopsy
- SURG.00113 - Artificial Retinal Devices
- SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
- SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer
- SURG.00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
- SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
- SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
- SURG.00150 - Leadless Pacemaker
- SURG.00151- Balloon Dilation of Eustachian Tubes
- TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation
- TRANS.00013 - Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
- TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
- TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
- TRANS.00035 - Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases
Archived medical policy numbers effective April 24, 2019
(The following policy numbers have been archived.)
- DRUG.00003 - Chelation Therapy (renumbered as MED.00127)
- DRUG.00034 - Insulin Potentiation Therapy (renumbered as MED.00128)
Re-categorized medical policies effective April 24, 2019
(The following policies were renumbered and had no changes to the policy position or criteria.)
- MED.00127 - Chelation Therapy (previously DRUG.00003)
- MED.00128 - Insulin Potentiation Therapy (previously DRUG.00034)
New medical policy effective April 24, 2019
(The following policy is new and determined to not have significant changes.)
- SURG.00152 - Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
Archived medical policies effective May 9, 2019
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- DRUG.00110 - Inotuzumab ozogamicin (Besponsa®) (recategorized as CG-DRUG-113)
- GENE.00002 - Preimplantation Genetic Diagnosis (recategorized as CG-GENE-06)
- GENE.00005 - BCR-ABL Mutatin Analysis (Qualitative) (recategorized as CG-GENE-07)
- GENE.00031 - Genetic Testing for PTEN Hamartoma Tumor Syndrome (recategorized as CG-GENE-08)
- GENE.00040 - Genetic Testing for CHARGE Syndrome (recategorized as CG-GENE-09)
- MED.00119 - High Intensity Focused Ultrasound (HIFU) for Oncologic Indications (recategorized as CG-MED-81)
- RAD.00066 - Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy (recategorized as CG-SURG-98)
- SURG.00048 - Panniculectomy, Abdominoplasty (recategorized as CG-SURG-99)
Archived medical policies effective June 24, 2019
(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)
- SURG.00033 - Cardioverter-Defibrillators (recategorized as CG-SURG-97)
Revised medical policies effective September 1, 2019
(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.)
- GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
- 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
- MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
New medical policy effective September 1, 2019
(The following policy is new and determined to not have significant changes.)
- GENE.00050 - Gene Expression Profiling for Coronary Artery Disease
As a result of coding updates in our claims system, claim edits for the policies and clinical guidelines listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary and/or investigational determination.
Effective September 1, 2019, we will be implementing coding updates in the claims system for the following policies listed below which may result in investigational/not medically necessary determinations for certain services.
- GENE.00001 - Genetic Testing for Cancer Susceptibility
- GENE.00007 - Cardiac Ion Channel Genetic Testing
- GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
- GENE.00023 - Gene Expression Profiling of Melanomas
The following new and revised medical policies were endorsed at the March 21, 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 March 19, 2019
(The following adopted guideline was updated with new HCPCS procedure code.)
- CG-MED-79 – Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
Revised medical policies effective March 28, 2019
(The following guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)
- CG-DRUG-96 - Ado-trastuzumab emtansine (Kadcyla®)
- CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
Revised medical policies effective March 28, 2019
(The following policies were updated with new procedure and/or diagnosis codes.)
- CG-DRUG-63 - Levoleucovorin calcium (Fusilev®)
- CG-DRUG-78 – Antihemophilic Factor and Clotting Factors
- CG-DRUG-98 - Bendamustine Hydrochloride
Revised clinical guidelines effective April 24, 2019
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
- CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
- CG-SURG-09 - Temporomandibular Disorders
Revised clinical guidelines effective April 24, 2019
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
- CG-DME-06 - Pneumatic Compression Devices for Lymphedema
- CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection
- CG-DRUG-51 - Romidepsin (Istodax®)
- CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration
- CG-DRUG-62 - Fulvestrant (FASLODEX®)
- CG-DRUG-67 - Cetuximab (Erbitux®)
- CG-DRUG-100 - Interferon gamma-1b (Actimmune®)
- CG-DRUG-101 - Ixabepilone (Ixempra®)
- CG-DRUG-102 - Olaratumab (Lartruvo™)
- CG-GENE-02 - Analysis of KRAS Status
- CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
- CG-MED-55 - Level of Care: Advanced Radiologic Imaging
- CG-MED-69 - Inhaled Nitric Oxide
- CG-MED-70 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
- CG-REHAB-08 - Private Duty Nursing in the Home Setting
- CG-SURG-74 - Total Ankle Replacement
- CG-SURG-76 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
- CG-SURG-78 - Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-80 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
- CG-TRANS-02 - Kidney Transplantation
Archived clinical guideline numbers effective April 24, 2019
(The following clinical guideline numbers have been archived.)
- CG-DRUG-25 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting (NOTE: This guideline has been renumbered as CG-MED-82.)
- CG-DRUG-47 - Level of Care: Specialty Pharmaceuticals (NOTE: This guideline has been renumbered as CG-MED-83.)
Re-categorized clinical guidelines effective April 24, 2019
(The following adopted guidelines were renumbered and had no changes to the policy position or criteria.)
- CG-MED-82 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting (NOTE: This guideline has been renumbered, previously CG-DRUG-25.)
- CG-MED-83 - Level of Care: Specialty Pharmaceuticals (NOTE: This guideline has been renumbered, previously CG-DRUG-47.)
Archived medical policy effective May 1, 2019
(The following policy has been archived and has been replaced by AIM guidelines.)
- CG-SURG-66 - Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
Adopted clinical guidelines effective May 9, 2019
(The following guidelines were previously medical policies and have been adopted with no significant changes.)
- CG-DRUG-113 - Inotuzumab ozogamicin (Besponsa®) (was DRUG.00110)
- CG-GENE-06 - Preimplantation Genetic Diagnosis Testing (was GENE.00002)
- CG-GENE-07 - BCR-ABL Mutation Analysis (was GENE.00005)
- CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome (was GENE.00031)
- CG-GENE-09 - Genetic Testing for CHARGE Syndrome (was GENE.00040)
- CG-SURG-99 - Panniculectomy and Abdominoplasty (was SURG.00048)
Adopted clinical guideline effective June 24, 2019
(The following guideline was previously a medical policy and has been adopted with no significant changes.)
- CG-SURG-97 - Cardioverter Defibrillators (was SURG.00033)
Revised clinical guidelines effective September 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-DME-44 - Electric Tumor Treatment Field (TTF)
- CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
- CG-MED-72 - Hyperthermia for Cancer Therapy
- CG-SURG-09 - Temporomandibular Disorders
As a result of coding updates in the claims system, claim edits for the policies and clinical guidelines listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary and/or investigational determination.
Effective September 1, 2019, we will be implementing coding updates in the claims system for the following clinical guidelines listed below which may result in not medically necessary determinations for certain services.
- CG-GENE-07 - BCR-ABL Mutation Analysis
- CG-GENE-09 - Genetic Testing for CHARGE Syndrome
On September 1, 2019, we will implement the following clinical guideline to support the review for unnecessary inter-facility transfers. This guideline impacts our commercial PPO and HMO products.
The inpatient services addressed in this clinical guideline will require advance authorization prior to the inter-facility transfer.
Inpatient Inter-Facility Transfers (CG-ANC-07)
This guideline addresses the clinical features of a hospitalized individual who may require services unavailable at an initial acute care facility (originating facility) necessitating a transfer to a second acute care facility (receiving facility).
Inter-facility transfers are considered medically necessary when one or more of the following criteria are met:
- The individual requires a medically necessary diagnostic or therapeutic service (for example, organ transplantation) which is not available at the originating facility; or
- The individual requires a level of care (for example, neonatal care unit or level 1 trauma center) which is not available at the originating facility; or
- The individual requires the services of a specialist to evaluate, diagnose or treat his or her condition when that specialist is not available in a timely manner at the originating facility (Note: Timeliness of care is a case/individual specific attribute. It may be appropriate for a medically stable individual to await availability of a specialist for several days while a medically unstable individual may require care more quickly); or
- The individual has received care at a specific prior institution for a condition not normally managed at the originating facility (for example, organ transplant recipient) and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue.
Inter-facility maternal transfer to allow birth mother to remain with neonate is considered medically necessary when neonate transfer meets the medically necessary criteria listed above and the birth mother requires continued hospitalization due to birth complications or other medically necessary conditions.
Inter-facility transfers between an originating facility and a receiving facility are considered not medically necessary when:
- The criteria above have not been met; or
- The services are primarily for the convenience of the individual, the individual’s family, the physician or the originating facility.
Beginning with dates of service on or after September 1, 2019, we will implement a new professional reimbursement policy, Ambulance Transportation. This policy allows reimbursement for ambulance transport and services and supplies associated with transport to the nearest facility equipped to treat the member. The policy details services that are included in the base rate, services reimbursed separately from the base rate, when ambulance response and treatment with no transport is reimbursable, and when services are not reimbursable. For additional information, visit the Reimbursement Policy page at anthem.com/provider. The following changes will be made to our Frequency Editing policy effective September 1, 2019:
- In the February 2018 edition of Network Update, we advised that we were revising our Frequency Editing policy to remove the frequency limits of one (1) per date of service and 18 per 365 days for definitive drug testing for HCPCS codes G0482 and G0483. Please note we are adding the language back into our policy dated September 1, 2019, to reflect that we still limit the frequency for these two codes.
- Beginning with dates of service on or after September 1, 2019, we will add a frequency limit of one (1) per date of service not to exceed one every three (3) years for CPT code 81528 (Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result.(e.g., Cologuard)).
- Beginning with dates of service on or after September 1, 2019, the following language will be removed.
- “The Health Plan will apply per day frequency maximums based on the CPT/HCPCS codes listed on the CMS Medically Unlikely Edit (MUE) listing that have a per day MUE Medicare Adjudication Indicator (MAI) “2.”
- The policy will apply frequency maximums based on CMS Medically Unlikely Edit (MUE), industry standards and/or code description.
For additional information, visit the Reimbursement Policy page at anthem.com/provider. As previously communicated in the April 2019 edition of Provider News, AIM Specialty Health® (AIM), a separate company, will begin to perform pre-service clinical review of rehabilitative (restoring function) and habilitative (enhancing function) services for Anthem commercial fully insured members beginning July 1, 2019. Currently, OrthoNet LLC is performing medical necessity reviews for physical and occupational therapy services for Anthem. These reviews, in addition to speech therapy service reviews, will transition to AIM.
AIM will manage physical therapy (PT), occupational therapy (OT) and speech therapy (ST) medical necessity reviews and will require pre-service clinical review for all outpatient facility and office-based rehabilitative and habilitative services following the initial evaluation. AIM will use the following Anthem Clinical UM Guidelines:
The clinical criteria used for these reviews can be found on our anthem.com Clinical UM Guidelines page. A complete list of CPT codes requiring pre-service clinical review for the AIM Rehabilitative Program is available on the AIM Rehabilitation microsite. There you can access additional helpful information such as order entry checklists and FAQs.
AIM will now begin accepting pre-service clinical review requests on June 24, 2019 for dates of service on and after July 1, 2019. Ordering and servicing providers may submit pre-service clinical review requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request clinical review.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number – 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.
Need training?
We invite you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the robust capabilities of the AIM ProviderPortalSM. Visit the AIM Rehab microsite to register for an upcoming training session. Providers currently submit prior authorization requests to AIM Specialty Health® (AIM) for outpatient diagnostic imaging services, cardiac procedures and sleep studies. As part of our ongoing quality improvement efforts, we want you to know that certain review requests require documentation that supports the clinical appropriateness of the request to be uploaded during the intake process.
When requested, providers must submit documentation from the patient’s medical record and/or participate in a prior authorization consultation with an AIM physician reviewer. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. We continue to streamline our medical specialty drug reviews by transitioning another drug review process from AIM to Anthem’s medical specialty drug review team.
What is changing?
- Beginning on June 15, 2019, for all requests, regardless of service date, providers will need to submit a new prior authorization request by contacting Anthem’s medical specialty drug review team:
- by phone at 833-293-0659 or
- by fax at 888-223-0550 or
- online access at availity.com available 24/7
- All inquiries about an existing request (initially submitted to AIM or Anthem), peer-to-peer review, or reconsideration will be managed by Anthem’s medical specialty drug review team.
What is not changing?
- Post service clinical coverage reviews and grievance and appeals process and teams will not change.
For your convenience here is a summary of the medical specialty drug changes:
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Action
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Contact
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Prior to June 15, 2019
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Submit a new prior authorization request
Inquire about an existing request
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Call AIM at 866-714-1107,
8:00 a.m. – 5:00 p.m.
or
Access online at availity.com available 24/7
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Beginning June 15, 2019
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Submit a new prior authorization request for medical specialty drug reviews
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Call Anthem at 833-293-0659 or fax us at 888-223-0550
or Access online at availity.com available 24/7
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|
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Inquire about an existing request (initially submitted to AIM or Anthem), peer-to-peer review, or reconsideration
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Call Anthem at 833-293-0659
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Effective for dates of service on and after September 1, 2019, the following specialty pharmacy codes from new or current clinical criteria or guideline will be included in our pre-service clinical review process.
Please note, inclusion of NDC code on your claim will help expedite the claim processing of drugs billed with a not otherwise classified (NOC) code.
The following clinical criteria or guideline will be effective September 1, 2019.
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Clinical Criteria/Guideline
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HCPCS or CPT Code(s)
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NDC Code(s)
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Drug
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CG-DRUG-98
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C9042, J9999
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42367-0520-25
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Belrapzo™
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ING-CC-0088
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C9399, J9999
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72187-0401-01
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Elzonris™
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ING-CC-0087
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C9399, J3590
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72171-0501-01
72171-0505-01
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Gamifant®
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ING-CC-0041
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C9399, J3590
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25682-0022-01
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Ultomiris™
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ING-CC-0086
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J3490
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50458-0028-00
50458-0028-02
50458-0028-03
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Spravato™
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For more information on 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 and other requirements, restrictions or limitations that apply to certain drugs, visit anthem.com/pharmacyinformation.
- To locate the commercial drug list, select ‘Click here to access your drug list’.
- To locate the Marketplace Select Formulary and pharmacy information, scroll down to ‘Select Drug Lists’, then select the applicable state’s drug list link.
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. We have identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To help ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, we will initiate postpay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.
We will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Anthem guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.
Please note: These coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patients utilize emergency room services.
500650MUPENMUB
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