 Provider News ConnecticutJune 2021 Anthem Connecticut Provider NewsHelp increase your vaccination rates and close gaps in care with these tools and strategies
Healthcare providers are often seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.
Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:
- Address disparities for vaccine-preventable diseases;
- Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine communications, providing vaccine education, and improving vaccine management and administration in your office;
- Access up-to-date vaccine guidance from the Centers for Disease Control and Prevention (CDC); and
- Connect with your state immunization program, local immunization coalition or other vaccine advocates in your community to collaborate.
Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.
Beginning with claims processed on or after June 1, 2021, we will enhance our claims editing systems to include an automated front end adjudication of claim edits.
Effective January 1, 2021, the Centers for Medicare & Medicaid Services (CMS) aligned evaluation and management (E/M) coding with several changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits, including providing professional providers with the choice to document office/outpatient E/M visits via medical decision making (MDM) or time. As a result, we have updated the communication titled “Evaluation and management services correct coding - professional” we published in the January 2021 issue of Provider News to capture this change, and for your convenience we have included the updated communication below.
Anthem continues 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. In an ongoing effort to promote accurate claims processing and payment, we are taking additional steps to assess selected claims for evaluation and management (E/M) services submitted by professional providers. Beginning on January 1, 2021, we will be using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.
Providers should report E/M services in accordance with the American Medical Association (AMA) CPT® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The coded service should reflect and not exceed the level needed to manage the member’s condition(s).
Claims will be selected from providers who are identified as coding at a higher E/M level as compared to their peers with similar risk-adjusted members. Prior to payment, Anthem will review the selected E/M claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is higher than the E/M code level supported on the claim. If the E/M code level submitted is higher than the E/M code level supported on the claim, Anthem reserves the right to:
- Deny the claim and request resubmission of the claim with the appropriate E/M level;
- Pend the claim and request documentation supporting the E/M level billed; and/or
- Adjust reimbursement to reflect the lower E/M level supported by the claim.
The maximum level of service for E/M codes will be based on the complexity of the medical decision-making or time and reimbursed at the supported E/M code level and fee schedule rate.
This initiative will not impact every level four (4) or five (5) E/M claim. Providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.
Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual.
If you have questions on this program, contact your contract manager or Network Relations.
Chances are that one out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.1 Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.2 For this reason, the National Committee for Quality Assurance (NCQA) recommends avoiding imaging for patients when there is no indication of an underlying condition. In a study published by the CDC, Early imaging for acute low back pain, the findings indicated not only was early imaging not associated with better outcomes, it also indicated that certain early imaging (MRI) was associated with an increased likelihood of disability and its duration.3
Watch this video to learn more
Take advantage of the Recommendation for Treating Acute Low Back Pain video located on the CDC website or use this link. The video also offers communications strategies to share with patients for effectively treating their low back pain.
HEDIS® measure: Use of Imaging Studies for Low Back Pain (LBP)
Description: The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The higher compliance score indicates appropriate treatment of low back pain.
Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.
Coding tips: Here are a few of the approved codes for the diagnosis and services associated with the LBP HEDIS measure. For a complete list, visit ncqa.org.
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CPT or ICD-10
|
Code
|
Description
|
|
CPT
|
72010, 72020, 72052, 72100
|
Imaging study
|
|
ICD-10
|
M47.898
|
Other spondylosis, sacral and sacrococcygeal region
|
|
ICD-10
|
M48.08
|
Spinal stenosis, sacral and sacrococcygeal region
|
|
ICD-10
|
M53.2X8
|
Spinal instabilities, sacral and sacrococcygeal region
|
|
ICD-10
|
M54.40
|
Lumbago with sciatica, unspecified side
|
|
ICD-10
|
M51.26 – M51.27
|
Other intervertebral disc displacement, lumbar lumbosacral region
|
|
ICD-10
|
M54.30 – M54.32
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Sciatica, unspecified, right side, left side
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|
ICD-10
|
M51.16-M51.17
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Intervertebral disc disorders with radiculopathy, lumbar region, lumbosacral region
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|
ICD-10
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M51.26-M51.27
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Intervertebral disc displacement, lumbar region, lumbosacral region
|
|
ICD-10
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M51.36-M51.37
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Other intervertebral disc degeneration, lumbar region, lumbosacral region
|
|
ICD-10
|
M51.86-M51.87
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Other intervertebral disc disorders, lumbar region, lumbosacral region
|
|
ICD-10
|
M99.53
|
Intervertebral disc stenosis of neural canal of lumbar region
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|
ICD-10
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S33.100A, S33.100D, S33.100S
|
Subluxation of unspecified lumbar vertebra; initial, subsequent, sequela encounter
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|
ICD-10
|
S33.5XXA
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Sprain of ligaments of lumbar spine; initial encounter
|
|
ICD-10
|
S33.6XXA
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Sprain of sacroiliac joint; initial encounter
|
|
ICD-10
|
S33.8XXA
|
Sprain of other parts of lumbar spine and pelvis; initial encounter
|
|
ICD-10
|
S33.9XXA
|
Sprain of unspecified parts of lumbar spine and pelvis; initial encounter
|
|
ICD-10
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S39.002A, S39.002D, S39.002S
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Unspecified injury of muscle, fascia, and tendon of lower back; initial, subsequent, sequela encounter
|
|
ICD-10
|
S39.82XA, S39.82XD, S39.82XS
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Other specified injuries of lower back; initial, subsequent, sequela encounter
|
Easily update demographic changes and much more, by simply submitting your updates through our online Provider Maintenance Form. Online update options include:
- name change
- tax ID change
- phone/fax number change
- provider leaving a group or a single location
- add an address location
- close a practice location
Visit the Provider Maintenance Form landing page to review more.
Important information about updating your practice profile:
- Change requests should be submitted using the online Provider Maintenance Form.
- Submit the change request online. No need to print, complete and mail, fax or email demographic updates.
- You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed.
- For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting.
You can check your directory listing on Anthem’s Find Care tool on anthem.com. Find Care is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To help ensure we have the most current and accurate information, please take a moment to access Find Care at anthem.com, select Providers, under Provider Overview, choose Find Care. You can log in as a guest to view how you and your practice are being displayed.
Nationally, seven percent of all claims are denied because they weren’t filed within the timely filing limits. At Anthem, we want your claims to be received on time, so they get paid on time. One way to ensure your claim isn’t denied because it wasn’t received within timely filing limits is to follow-up with your clearinghouse on a regular basis.
When you send claims electronically through a clearinghouse, if errors are identified on the claims, they won’t get submitted for payment. Checking in regularly with your clearinghouse is key to identifying claims errors. This gives you the opportunity to correct claims quickly, avoiding delays in filing and running the risk of a claim denial because it wasn’t filed within the timely filing limit.
Have you confirmed the patient is an Anthem member?
Another reason claims are delayed is because the claim was filed with Anthem, but it should have been filed with another insurance company first. To make sure your claim is received on time, confirm the member’s primary insurance information each time they visit your office. To check the member’s eligibility or to get a digital copy of the member’s ID card, log onto Availity.com. From the Patient Registration tab, use the Eligibility and Benefits Inquiry tool for a quick and easy search.
Checking your claims status
It is easy to check your claim online to confirm we’ve received it. Log onto Availity.com and use the Claims & Payment tab for the Claims Status tool. You may also be able to check the claim to verify no adjustments are needed through the Claims Status Listing application located on the Payer Spaces home page.
The sooner you file the faster your claim is paid
Filing your claim within the timely filing limits can eliminate claim denials. If your claim denies because it was filed late, we will deny the claim as outlined in your contract with us. It is important to note that the member cannot be billed for denied claims that were not filed timely.
Use these helpful tips when filing your claims because we understand that timely payments are as important as timely filing.
A new copy feature that will significantly speed up your authorization workflow is now available on Interactive Care Reviewer (ICR). Submit multiple requests in a fraction of the time it takes to create an entire case. You can choose to create a duplicate case or select specific elements of a case to copy for a different patient*. The copy feature will be particularly useful for facility staff requesting multiple authorizations for inpatient emergent/urgent admissions and providers who request multiple authorizations for the same services.
You have two options for copying a submitted case:
- Immediately copy a case you just submitted from the ICR dashboard. Select Click here from the blue bar message located at the top of the dashboard.
- Copy a case that has been submitted within the past 45 days from the ICR Case Overview. Select the Copy Case button.
The Case Type, Request Type, Place and Type of Service is duplicated onto the new case. You will be given the option to select the following case details to copy:
- Diagnosis code and procedure code
- Inpatient length of stay
- Requesting provider and contact information
- Servicing facility
- Inpatient length of stay
- Servicing provider
Simply key in the patient’s details* and include the clinical details to complete the new case.
*Please note: To duplicate the authorization request, the patient needs to be enrolled in the same state and health plan as the patient’s case that is being copied, i.e., Anthem Blue Cross and Blue Shield in Connecticut. Federal Employee Program (FEP) requests can be duplicated for any state.
Want to learn more about the new ICR copy feature?
- Attend our monthly live webinar sessions: Introduction to Interactive Care Reviewer. Register here.
- Or, view and download an illustrated job aid – Interactive Care Reviewer Copy Feature. Find the job aid on the Custom Learning Center. From Availity’s home page select Payer Spaces | Anthem tile | Custom Learning Center | Resources. To narrow the results, apply the Interactive Care Reviewer filter.
Are you aware there are two self-service learning centers where you can find training and educational materials that will help you learn about the transactions and tools on the Availity Portal?
- Availity Learning Center: Your resource for information related to multi-payer tools and transactions.
- Custom Learning Center: Your resource for information related to Anthem tools that are accessed through the Availity Portal.
Availity Learning Center
Dive into the Availity Learning Center for training materials related to multi-payer functionality. Availity works with many payers to give you the most consistent experience available. For learning opportunities on basic capabilities that you access on behalf of multiple payers, the Availity Learning Center is your go-to source.
- From the secure Availity Portal home page select Help & Training > Get Trained to open the Learning Center catalog.
- Once you open the Availity Learning Center you can enroll for new administrator and new user onboarding modules, other topic specific courses, and live webinars.
Custom Learning Center
Explore Anthem’s Custom Learning Center application on Payer Spaces to increase your understanding of how our self-service digital tools function. The Custom Learning Center opens on the Catalog page where you will find videos and courses. Select Resources from the upper left corner of Custom Learning Center to access reference guides.
Use these self-service learning options to help you get up to speed quickly on Availity transactions and Anthem digital tools.
Availity offers digital solutions that can assist your organization in many ways by visiting the Availity Support Community. Below are the options available for support:
- Watch demos
- Troubleshooting
- FAQs
- Support requests
- Network outages
- Release notes
Log into Availity > Select Help & Training > Availity Support > Select the Organization, and continue to reach the Availity Support Community.
Below are the support ticket actions available:
Open
- Select the Contact Support
- On the Contact Support page, complete the fields in the Create Casesection, and then select Start Case.
- Complete the fields on the Contact Support page.
View
Select the My Support Requests tile.
- Select a ticket to see more information about the ticket.
- To filter the tickets by their status, do one of the following:
- Select the Open tab to display your organization's open tickets.
- Select the Closed tab to view your organization's closed tickets.
- Select the Archived tab to view your organization's archived tickets.
- Select Contact Support to open a new support ticket.
Update
Once a support ticket has been created, you can update/edit information in the ticket.
- On the Support Tickets page, select the ticket you want to update.
- On the ticket detail page, select Edit Case.
- Update/edit the information.
- When you've completed your changes, select Save.
Add comments
You can add comments to provide additional information for a support ticket.
- On the Support Tickets page, select the ticket to which you want to add comments.
- On the ticket detail page, type your comment in the Add commentfield, then select Comment. Comments display in the Case Comments section on the ticket detail page.
Attach documentation
Use this feature to attach a file that could assist Availity in troubleshooting your issue. This feature supports most file types, including Word, Excel, and .jpg. If you receive an error message preventing you from uploading a specific file type, try saving the file in a different format.
- On the Support Tickets page, select the ticket to which you want to attach files.
- In the Filessection of the ticket details page, select Upload File to open the Add Attachment window
Change status
You should change a support ticket's status when you want to perform functions such as close, re-open, or archive a support ticket.
- On the Support Tickets page, select the ticket whose status you want to change.
- On the ticket detail page, select Change Status.
- Select the status that you want from the Statusfield, and then select Save.
- Closed– Select this status to close the support ticket.
- Re-opened– Select this status to re-open the support ticket. (Do not reopen a case to report a new issue, open a new case instead).
- Archived– Select this status to archive the support ticket. When you archive a ticket, it's moved from a closed queue to an archived queue. Archiving tickets helps keep your closed tickets queue manageable.
Contact Availity Client Services
If you need to speak with an Availity Client Services representative, call 800-AVAILITY (282-4548).
Our digital-first initiative allows you to submit EDI corrected claims using the Availity Portal or through Electronic Data Interchange (EDI). The corrected claims process begins when a claim has already been adjudicated. Multiple types of errors that occur can typically be corrected quickly with the options below. As a reminder, the corrected claim must be received within the claim timely filing period.
Availity portal corrected claim submission
You can recreate a claim and submit it as a replacement or cancellation (void) of the original claim if we have already accepted the original claim for processing.
Follow these steps:
- In the Availity portal menu, select Claims & Payments, and then select ProfessionalClaim or Facility Claim, depending on which type of claim you want to correct.
- Enter the claim information, and set the billing frequency and payer control number as follows:
- Replacement of Prior Claim or Void/Cancel of Prior Claim
- Billing Frequency(or Frequency Type) field, in the Claim Information section (for professional and facility claims) or Ancillary Claim/Treatment Information section (for dental claims).
- Set the Payer Control Number (ICN / DCN)(or Payer Claim Control Number) field to the claim number assigned to the claim by Anthem. You can obtain this number from the 835 ERA or Remittance Inquiry on Payer Spaces.
- Submit the claim.
EDI corrected claim submission
Corrected claims submitted electronically must also have the applicable frequency code. A frequency code indicates the claim is a correction of a previously submitted and adjudicated claim. Providers should use one of the following:
- For corrected professional (837P) claims, use one the following frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
- 7 – Replacement of Prior Claim\Corrected Claim
- 8 – Void/Cancel Prior Claim
- For corrected institutional (837I) claims, use bill type frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
- 0XX7 – Replacement of Prior Claim
- 0XX8 – Void/Cancel Prior Claim
Please check with your practice management software vendor, billing service or clearinghouse for full details for submitting corrected claims.
We encourage you and your staff to use the digital methods available to submit corrected claims to save costs in mailing, paper, and your valuable time.
Effective July 19, 2021, Anthem and AIM Specialty Health® (AIM), a specialty benefits management company, will launch a new Back Pain Management Program for Anthem fully-insured members. AIM works with leading insurers to help improve health care quality and manage costs for today’s most complex and prevalent tests and treatments, and to help promote care that is appropriate, safe and affordable. In pursuit of that commitment, we have created a new Back Pain Management Program to educate and support members to help reduce risk of chronicity, and minimize recurrences and complications as they navigate through their back pain journey.
The program will use predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.
Our targeting management process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors
- Risk stratification to help ensure the appropriate level of support is provided
- Targeted outreach to members through our digital engagement platform, email and telephone
- Customized education and support of provider treatments based on member’s specific needs
- Education and support of services such as behavioral health as appropriate
Members included in the new program
All fully-insured members currently participating in AIM and Anthem programs are included. The following members are excluded: self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR, and the Federal Employee Program® (FEP®).
The AIM Back Pain Program microsite provides access to helpful information and tools such as program information and FAQs.
AIM Back Pain Program informational webinars
We invite you to take advantage of a free informational webinar that will introduce you to the program. Go to the AIM Back Pain Program microsite to register for an upcoming webinar.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services
Advanced Imaging of the Spine – updates by section
- Congenital vertebral defects
- New requirement for additional evaluation with radiographs
- Scoliosis
- Defined criteria for which presurgical planning is indicated
- Requirement for radiographs and new or progressive symptoms for postsurgical imaging
- Spinal dysraphism and tethered cord
- Diagnostic imaging strategy limiting the use of CT to cases where MRI cannot be performed
- New requirement for US prior to advanced imaging for tethered cord in infants age 5 months or less
- Multiple sclerosis
- New criteria for imaging in initial diagnosis of MS
- Spinal infection
- New criteria for diagnosis and management aligned with IDSA and University of Michigan guidelines
- Axial spondyloarthropathy
- Defined inflammatory back pain
- Diagnostic testing strategy outlining radiography requirements
- Cervical injury
- Aligned with ACR position on pediatric cervical trauma
- Thoracic or lumbar injury
- Diagnostic testing strategy emphasizing radiography and limiting the use of MRI for known fracture
- Remove indication for follow-up imaging of progressively worsening pain in the absence of fracture or neurologic deficits
- Syringomyelia
- Removed indication for surveillance imaging
- Non-specific low back pain
- Aligned pediatric guidelines with ACR pediatric low back pain guidelines
Advanced Imaging of the Extremities – updates by section
- Osteomyelitis or septic arthritis; myositis
- Removed CT as a follow up to nondiagnostic MRI due to lower diagnostic accuracy of CT
- Epicondylitis and tenosynovitis – long head of biceps
- Removed due to lack of evidence supporting imaging for this diagnosis
- Plantar fasciitis and fibromatosis
- Removed CT as a follow up to nondiagnostic MRI due to lower diagnostic accuracy of CT
- Added specific conservative management requirements
- Brachial plexus mass
- Added specific requirement for suspicious findings on clinical exam or prior imaging
- Morton’s neuroma
- Added requirements for focused steroid injection, orthoses, plan for surgery
- Adhesive capsulitis
- Added requirement for planned intervention (manipulation under anesthesia or lysis of adhesions)
- Rotator cuff tear; labral tear – shoulder; labral tear - hip
- Defined specific exam findings and duration of conservative management
- Recurrent labral tear now requires same criteria as an initial tear (shoulder only)
- Triangular fibrocartilage complex tear
- Added requirement for radiographs and conservative management for chronic tear
- Ligament tear – knee; meniscal tear
- Added requirement for radiographs for specific scenarios
- Increased duration of conservative management for chronic meniscal tears
- Ligament and tendon injuries – foot and ankle
- Defined required duration of conservative management
- Chronic anterior knee pain including chondromalacia patella and patellofemoral pain syndrome
- Lengthened duration of conservative management and specified requirement for chronic anterior knee pain
- Intra-articular loose body
- Requirement for mechanical symptoms
- Osteochondral lesion (including osteochondritis dissecans, transient dislocation of patella)
- New requirement for radiographs
- Entrapment neuropathy
- Exclude carpal and cubital tunnel
- Persistent lower extremity pain
- Defined duration of conservative management (6 weeks)
- Exclude hip joint (addressed in other indications)
- Upper extremity pain
- Exclude shoulder joint (addressed in other indications)
- Diagnostic testing strategy limiting use of CT to when MRI cannot be performed or is nondiagnostic
- Knee arthroplasty, presurgical planning
- Limited to MAKO and robotic assist arthroplasty cases
- Perioperative imaging, not otherwise specified
- Require radiographs or ultrasound prior to advanced imaging
Vascular Imaging – updates by section
Alternative non-vascular modality imaging approaches, where applicable
- Hemorrhage, intracranial
- Clinical scenario specification of subarachnoid hemorrhage indication.
- Addition of pediatric intracerebral hemorrhage indication.
- Horner’s syndrome; pulsatile tinnitus; trigeminal neuralgia
- Removal of management scenario to limit continued vascular evaluation
- Stroke/TIA; stenosis or occlusion (intracranial/extracranial)
- Acute and subacute time frame specifications; removal of carotid/cardiac workup requirement for intracranial vascular evaluation; addition of management specifications
- Sections separated anatomically into anterior/posterior circulation (carotid artery and vertebral or basilar arteries, respectively)
- Pulmonary embolism
- Addition of non-diagnostic chest radiograph requirement for all indications
- Addition of pregnancy-adjusted YEARS algorithm
- Peripheral arterial disease
- Addition of new post-revascularization scenario to both upper and lower extremity PAD evaluation
As a reminder, ordering and servicing providers may submit prior authorization 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 authorization.
- 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.
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 and upcoming guidelines here.
Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Joint Surgery - updates by section
- Further defined criteria for home physical therapy
- Removed cognitive behavioral therapy as a conservative care modality for extremity
- Added indication for diagnostic arthroscopy
- Standardized radiographic criteria to align with lateral release criteria
- Adhesive capsulitis - added history of trauma or post-operative contracture as a requirement
- Tendinopathy - removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for SLAP repair or have suggestive MRI findings
- Hip arthroscopy - removed complementary alternative medicine as not typically done for the hip
- Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) - removed age as an exclusion for FAIS but further define radiographic exclusions
- Unicompartmental knee arthroplasty/partial knee replacement - added degenerative change of the patellofemoral joint as a contraindication
- Arthroscopically assisted lysis of adhesions - added ligamentous or joint reconstruction criteriaAdded criteria for plica resection
Spine Surgery - updates by section
- Further defined criteria for home physical therapy
- Added standard conservative management requirement for instability to align with spinal stenosis indications
- Added new comprehensive indication for tethered cord syndrome
As a reminder, ordering and servicing providers may submit prior authorization 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 authorization.
- 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.
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 and upcoming guidelines here.
Osteoporosis affects more than 50 million Americans. Treatment options are better and bone fractures are more preventable the sooner it is detected. Does your patient meet the criteria for a DEXA bone scan? Initial or repeat bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions.
To assist providers with administrative requirements for bone mineral density (BMD) studies, the Federal Employee Program (FEP) medical policy and utilization guidelines can be found on fepblue.org. The medical policy is titled, Medical Policy MPM 6.01.01, Bone Mineral Density Studies. Below is an outline of this policy.
Policy Statement:
An initial measurement of central (hip/spine) BMD using dual x-ray absorptiometry (DXA) may be considered medically necessary to assess future fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis.
BMD testing may be indicated under the following conditions:
- Women age 65 and older, independent of other risk factors
- Men age 70 and older, independent of other risk factors
- Younger postmenopausal women with an elevated risk factor assessment (see policy guidelines)
- Men age 50 to 70 with an elevated risk factor assessment (see policy guidelines)
- Adults with a pathologic condition associated with low bone mass or increased bone loss
- Adults taking a medication associated with increased bone loss
Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry for individuals who previously tested normal may be considered medically necessary at an interval not more frequent than every 3 to 5 years; the interval depends on an updated patient fracture risk assessment.
Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-2 years as follows:
- Individuals with a baseline evaluation of osteopenia (BMD T-score of -1.0 to -2.5)
- Adults with a pathologic condition associated with low bone mass or increased bone loss
- Adults taking a medication associated with increased bone loss
Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-3 years in individuals who are receiving pharmacologic treatment for osteoporosis when the information will affect treatment decisions (continuation, change in drug therapy, cessation or resumption of drug therapy).
Peripheral (lower arm, wrist, finger or heel) BMD testing may be considered medically necessary when conventional central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism, where peripheral DXA at the forearm (i.e., radius) is essential for evaluation.
Dual x-ray absorptiometry of peripheral sites is considered investigational except as noted above.
BMD measurement using ultrasound densitometry is considered not medically necessary.
BMD measurement using quantitative computed tomography is considered investigational.
If you have any questions about Federal Employee benefits or medical policy information, please contact Customer Service at the applicable number below:
- Connecticut providers - 800-438-5356
- Maine providers - 800-722-0203
- New Hampshire providers - 800-852-3316
Prior authorization updates
Effective for dates of service on and after September 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
**ING-CC-0191
|
J3490, J9999, C9399
|
Pepaxto
|
|
**ING-CC-0192
|
J3490, C9399
|
Cosela
|
|
*ING-CC-0193
|
J3490, C9399
|
Evkeeza
|
|
*ING-CC-0194
|
J3490
|
Cabenuva
|
|
*ING-CC-0167
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J9999, J3590, C9399
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Riabni
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* Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team.
** Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Visit our website to access the clinical criteria information.
Please note, inclusion of a national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Step therapy updates
Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process. In addition, please note that Inflectra is changing to preferred status effective July 1, 2021.
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Clinical Criteria
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Preferred Status
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Drug
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|
ING-CC-0062
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Preferred
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Inflectra
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ING-CC-0062
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Preferred
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Remicade
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ING-CC-0062
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Non-preferred
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Avsola
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ING-CC-0062
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Non-preferred
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Renflexis
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Prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications is managed by AIM.
Visit our website to access the clinical criteria information.
Please note, inclusion of a national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
The following clinical criteria documents were endorsed at a Clinical Criteria meeting. Visit our website to access the clinical criteria information.
Reviewed clinical criteria effective August 1, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0008: Subcutaneous Hormonal Implants
- ING-CC-0012: Brineura (cerliponase alfa)
- ING-CC-0013: Mepsevii (vestronidase alfa)
- ING-CC-0017: Xiaflex (collagenase clostridium histolyticum)
- ING-CC-0018: Lumizyme (alglucosidase alfa)
- ING-CC-0021: Fabrazyme (agalsidase beta)
- ING-CC-0022: Vimizim (elosulfase alfa)
- ING-CC-0023: Naglazyme (galsulfase)
- ING-CC-0024: Elaprase (idursufase)
- ING-CC-0025: Aldurazyme (laronidase)
- ING-CC-0028: Benlysta (belimumab)
- ING-CC-0029: Dupixent (dupilumab)
- ING-CC-0033: Xolair (omalizumab)
- ING-CC-0034: Hereditary Angioedema Agents
- ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0041: Complement Inhibitors
- ING-CC-0044: Exondys 51 (eteplirsen)
- ING-CC-0049: Radicava (edaravone)
- ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0070: Jetrea (ocriplasmin)
- ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy
- ING-CC-0077: Palynziq (pegvaliase-pqpz)
- ING-CC-0079: Strensiq (asfotase alfa)
- ING-CC-0081: Crysvita (burosumab-twza)
- ING-CC-0082: Onpattro (patisiran)
- ING-CC-0148: Agents for Hemophilia B
- ING-CC-0152: Vyondys 53 (golodirsen)
- ING-CC-0156: Reblozyl (luspatercept)
- ING-CC-0159: Scenesse (afamelanotide)
- ING-CC-0170: Uplizna (inebilizumab-cdon)
- ING-CC-0172: Viltepso (viltolarsen)
- ING-CC-0173: Enspryng (satralizumab-mwge)
- ING-CC-0188: Imcivree (setmelanotide)
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 any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacyinformation. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
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.
As a reminder, Anthem Blue Cross and Blue Shield (Anthem) Medicare Advantage does not allow separate reimbursement for claims that have been identified as a readmission to the same hospital for the same, similar or related condition unless provider, federal or CMS contracts and/or requirements indicate otherwise, as further described in the existing reimbursement policy located our website.
If Anthem Medicare Advantage determines that this reimbursement policy has not been followed, Anthem Medicare Advantage may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Anthem Medicare Advantage and Anthem Medicare Advantage policies.
For more detailed information on the Inpatient Readmissions reimbursement policy, please visit our reimbursement policies website.
The medical policies, clinical utilization management (UM) guidelines and third party criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The medical policies and clinical UM guidelines below are followed in the absence of Medicare guidance.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit our website.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *CG-LAB-17 - Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
- Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
- *ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
- Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary
- *CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
- Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
- *CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor GM-CSF) as not medically necessary for all liver-related indications
- *CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
- Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
- Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
- Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications
- CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
- A new Clinical Guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
- CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions
- A new Clinical Guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
- CG-SURG-110 - Lung Volume Reduction Surgery
- A new Clinical Guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021
AIM Specialty Health®* Clinical Appropriateness Guideline updates. To view AIM guidelines, visit the AIM Specialty Health page.
- The Small Joint Surgery guideline has been revised and will be effective on March 14, 2021.
- The following guidelines have been revised and will be effective on June 4, 2021:
- * Imaging of the Spine
- * Imaging of the Extremities
- * Vascular Imaging
- * Joint Surgery
- * Spine Surgery
Medical policies
On February 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect June 4, 2021.
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Publish date
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Medical policy number
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Medical policy title
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New or revised
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|
4/7/2021
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*ANC.00008
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Cosmetic and Reconstructive Services of the Head and Neck
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Revised
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2/18/2021
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SURG.00121
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Transcatheter Heart Valve Procedures
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Revised
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2/18/2021
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SURG.00145
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Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
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Revised
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Clinical UM guidelines
On February 11, 2021, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on February 25, 2021. These guidelines take effect June 4, 2021.
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Publish date
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Clinical UM guideline number
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Clinical UM guideline title
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New or revised
|
|
4/7/2021
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*CG-LAB-17
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Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
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New
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|
2/18/2021
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CG-GENE-21
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Cell-Free Fetal DNA-Based Prenatal Testing
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Revised
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4/7/2021
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CG-MED-26
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Neonatal Levels of Care
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Revised
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2/18/2021
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CG-MED-87
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Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
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Revised
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4/7/2021
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*CG-OR-PR-04
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Cranial Remodeling Bands and Helmets (Cranial Orthotics)
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Revised
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2/18/2021
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CG-SURG-55
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Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
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Revised
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4/7/2021
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CG-SURG-71
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Reduction Mammoplasty
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Revised
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4/7/2021
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*CG-SURG-78
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Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
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Revised
|
|
4/7/2021
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*CG-SURG-82
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Bone-Anchored and Bone Conduction Hearing Aids
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Revised
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|
4/7/2021
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CG-SURG-97
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Cardioverter Defibrillators
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Revised
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Effective September 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.
Goal length of stay (GLOS) for inpatient and surgical care (ISC)
|
Guideline
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MCG Code
|
24th Edition GLOS
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25th Edition GLOS
|
|
Aortic Coarctation, Angioplasty
|
S-152
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Ambulatory or 1 day postoperative
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Ambulatory
|
|
Cardiac Septal Defect: Atrial, Transcatheter Closure
|
W0016
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Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Esophageal Diverticulectomy, Endoscopic
|
S-445
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Ambulatory or 1 day postoperative
|
Ambulatory
|
|
Gastrectomy, Partial - Billroth I or II
|
S-510
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4 or 6 days postoperative
|
5 days postoperative
|
|
Hernia Repair (Non-Hiatal)
|
S-1305
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Ambulatory or 1 day postoperative
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Ambulatory
|
|
Pancreatectomy
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S-1200
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5 or 7 days postoperative
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6 days postoperative
|
|
Pyloroplasty and Vagotomy
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S-990
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4 or 6 days postoperative
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4 days postoperative
|
|
Cervical Laminectomy
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W0097
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2 days postoperative
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Ambulatory or 2 days postoperative
|
|
Lumbar Diskectomy, Foraminotomy, or Laminotomy
|
W0091
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Ambulatory or 1 day postoperative
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Ambulatory
|
|
Removal of Posterior Spinal Instrumentation
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S-530
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1 day postoperative
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Ambulatory or 1 day postoperative
|
|
Shoulder Hemiarthroplasty
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W0138
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1 day postoperative
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Ambulatory or 1 day postoperative
|
|
Spine, Scoliosis, Posterior Instrumentation, Pediatric
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W0156
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4 days postoperative
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3 days postoperative
|
|
Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent
|
S-190
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5 or 6 days postoperative
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5 days postoperative
|
|
Prostatectomy, Transurethral Resection (TURP)
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S-970
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Ambulatory or 1 day postoperative
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Ambulatory
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|
Urethroplasty
|
S-1172
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Ambulatory or 1 day postoperative
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Ambulatory
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New guidelines for behavioral health care (BHC) and recovery facility care (RFC)
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Body system
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Guideline title
|
MCG - code
|
|
Withdrawal Management
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Withdrawal Management, Adult: Inpatient Care
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B-031-IP
|
|
Withdrawal Management
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Withdrawal Management, Adult: Intensive Outpatient Program
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B-031-IOP
|
|
Withdrawal Management
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Withdrawal Management, Adult: Outpatient Care
|
B-031-AOP
|
|
Withdrawal Management
|
Withdrawal Management, Adult: Partial Hospital Program
|
B-031-PHP
|
|
Withdrawal Management
|
Withdrawal Management, Adult: Residential Care
|
B-031-RES
|
|
Cardiology
|
Hypertension
|
M-5197
|
|
Cardiology
|
Peripheral Vascular Disease (PVD)
|
M-7087
|
|
Nephrology
|
Rhabdomyolysis
|
M-7095
|
|
Nephrology
|
Encephalopathy
|
M-7100
|
|
Thoracic Surgery
|
Rib Fracture
|
M-5545
|
Customizations to MCG care guidelines 25th edition
Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented.
Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - revised clinical indications for procedure and added the following.
- Need for acute TMS treatment, up to six weeks
- Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
- Continuation of acute treatment, up to six months
- TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
- Maintenance TMS treatment
- Continuation of acute TMS treatment for longer than six months
- TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, anxiety disorders, bipolar depression, neurodevelopmental disorders, obsessive-compulsive disorder, peripartum depression, post-traumatic stress disorder, substance use disorders, Tourette's syndrome.
To view a detailed summary of customizations, visit this link, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.
For questions, please contact the provider services at the number on the back of the member’s ID card.
The Group Retiree Medicare Advantage membership is experiencing a high volume of enrollment, and as we continue to grow, we wanted to send these reminders for our PPO plans for Anthem Blue Cross and Blue Shield (Anthem). Group Retiree Medicare Advantage memberships may include the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare and accepts the member’s PPO plan. These PPO plans also offer benefits that original Medicare doesn’t cover, including an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online* and SilverSneakers®.*
If you are already part of our Medicare Advantage PPO network, thank you. The attached FAQ will be helpful as you grow your practice and serve members who may be new to our Group Retiree PPO plans.
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