 Provider News ConnecticutJune 2022 Anthem Connecticut Provider NewsBeginning with claims processed on or after July 1, 2022, Anthem will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT® codes 99381-99397) is billed with a problem-oriented E/M service (CPT codes 99202-99215) and appended with modifier 25 (for example, CPT code 99393 billed with CPT code 99213-99225).
According to the American Medical Association (AMA) CPT Guidelines, E/M services must be “significant and separately identifiable” in order to appropriately append modifier 25. Based on review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.
Providers who believe their medical record documentation supports a significant and separately identifiable E/M service should follow the Claims Payment Dispute process (including submission of such with the dispute) as outlined in the provider manual.
If you have questions on this program, contact your contract manager or Provider Experience.
Register today for the Exploring the Intersection of Race and Disability forum hosted by Anthem and Motivo* for Anthem providers on June 22, 2022.
Anthem is committed to making healthcare simpler and reducing health disparities. We believe that open discussions about the disability experience for people of and reducing implicit bias, is critical to improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race on our health and wellbeing. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.
Wednesday, June 22, 2022
4 p.m. to 5:30 p.m. ET
Register today!
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Please review your demographic information in our online provider directories to ensure members and fellow providers can reach you.
Submit your updates by using our online Provider Maintenance Form. Update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
You will receive an email to acknowledge your submitted Provider Maintenance Form. Visit the Provider Maintenance Form landing page for complete instructions.
Thank you for doing your part to help keep our online provider directories up to date.
One in every 10 Americans have diabetes, but one in every five don’t know they have it. This makes annual testing important to those who have symptoms. For those patients who are diagnosed, testing is vitally important to reducing serious health complications and the costs associated with them. It isn’t always easy to help patients understand the need for annual testing. The Centers for Disease Control and Prevention has resources you can use in your practice to educate, inform, and hopefully motivate your patients. Visit their website cdc.gov and use their Health Care Providers section to access patient education programs, prevention toolkits and more.
Measure up
Comprehensive Diabetes Care (CDC): This HEDIS® measure evaluates Anthem members aged 18 to 75 years with type 1 or type 2 diabetes. Each year, members with type 1 or type 2 diabetes should have:
- Hemoglobin A1c (HbA1c) testing - HbA1c control (< 8%)
- Eye exam (retinal) performed
- Evaluation for kidney disease
- BP control (< 140/90 mm Hg)
|
Code type
|
Description
|
Code
|
|
ICD-10
|
Type 1 diabetes mellitus without complications
|
E10.9
|
|
ICD-10
|
Type 2 diabetes mellitus without complications
|
E11.9
|
|
ICD-10
|
Other specified diabetes mellitus without complications
|
E13.9
|
Beginning in June 2022, Anthem will implement new processes for providers to validate the information we have in our online provider directories.
Individual providers
We are partnering with CAQH to assist us in validation for individual providers. Providers will receive communications from CAQH asking them to register for CAQH ProView®, the online provider data-collection service, where providers can review and verify their information, as well as provide updates that may be needed.
Facilities and groups
We are also partnering with First Source to assist us in validating information for facilities and groups. A file will be sent to providers with the information we have in our systems. We are asking that providers review this file, validate correct information and provide updates as needed.
If you have questions, please contact Provider Service.
Effective with dates of service on or after September 1, 2022, Anthem will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.
Prior to payment, we will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, we will reimburse using CPT code 99211.
Professional providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service should 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 Provider Experience representative.
In our efforts to improve the health of humanity, Anthem has made a long-term commitment to reducing morbidity and mortality associated with substance use disorder. In recent years, with a focus on primary and secondary prevention, we’ve seen significant reductions in the use of inappropriate opioid prescriptions for acute and chronic pain as well as the promotion of and increased use of safe alternatives for pain management. Similarly, we have been a leader in increasing access to evidence-based treatment for substance use disorders including medication for addiction treatment (MAT).
Unfortunately, the COVID-19 pandemic has hindered the nation’s progress as evidenced by a 30% rise nationally in deaths from overdose with the majority being from opioids (CDC). The impact on overdose rates from the pandemic requires that we also increase our efforts at preventing deaths from opioid overdose. Specifically, there is a need/opportunity to work collaboratively with our partners in the community to increase access to the opioid overdose reversal drug naloxone (aka “Narcan”). Our internal claims data from the second quarter of 2021 shows that approximately 20% of members experiencing a non-fatal opioid overdose are starting and continuing with medication for opioid use disorder (MOUD) which can include buprenorphine, methadone or naltrexone. However, only 7% of these members have evidence of filling a prescription for naloxone. These rates have improved from a 2015 baseline of approximately 1%, but we have significant room for improvement.
What can we do to address this?
First, be an advocate for destigmatizing substance use disorders by supporting efforts to improve access to MOUD and harm reduction strategies including the use naloxone. We can learn more at www.Shatterproof.org, an organization we have historically supported.
Second, educate your patients about substance use disorders including how to spot them in a loved one, and how to support them when considering change. Visit https://www.samhsa.gov/find-help/recovery for more information.
Third, learn more about the life saving opioid overdose reversal drug naloxone including how to obtain it, and how to administer it. See www.getnaloxonenow.org for more information.
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health sleep disorder management clinical appropriateness guidelines. As 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.
- Established sleep disorder (OSA or other) – follow-up laboratory studies – added indication for one follow-up in-lab sleep study as appropriate following insertion of a hypoglossal nerve stimulator
- Multiple sleep latency testing (MSLT) and/or maintenance of wakefulness testing (MWT) – new indication for MWT in occupational safety evaluation
- Management of OSA using oral appliances (OA) – limit guideline for oral appliance use to patients 16 years and older
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 at 866-714-1107, Monday–Friday, 8 a.m.–5 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 11, 2022, the following updates will apply to the AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines. As 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.
Updates by guideline
Imaging of the spine:
- Perioperative and periprocedural imaging – added requirement for initial evaluation with radiographs
Imaging of the extremities:
- Trauma – added CT as an alternative to MRI for tibial plateau fracture; added indication for evaluation of supracondylar fracture
- Rotator cuff tear – combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
- Shoulder arthroplasty – modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
- Perioperative imaging – excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty
Vascular imaging:
- Stenosis or occlusion, extracranial carotid arteries: - New indications for post neck irradiation, incidental carotid calcification scenarios.
- Stroke/TIA, extracranial evaluation - Subacute stroke/TIA: CTA/MRA neck allowed without prerequisite ultrasound (US), in alignment with 2021 AHA/ASA guidelines.
- Chronic stroke/TIA - New indication; modality approach by circulation presentation.
- Pulmonary Embolism - Removal of nondiagnostic CXR requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID infection, etc).
- Imaging study modality and/or site expansion - pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
- Stenosis or occlusion, extracranial carotid arteries - Post-revascularization scenario aligned with SVS guidelines to allow annual surveillance regardless of residual stenosis.
- Aneurysm of the abdominal aorta or iliac arteries - Management/surveillance scenarios aligned with SVS guidelines.
- Upper or lower extremity peripheral arterial disease (PAD):
- Suspected PAD without physiologic testing (including exercise testing) not indicated
- New indication for popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)
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 at 866-714-1107, Monday–Friday, 8 a.m.–5 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 11, 2022, the following updates will apply to the AIM Specialty Health Musculoskeletal Clinical Appropriateness Guidelines. As 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.
Updates by guideline
Spine surgery:
- Lumbar disc arthroplasty – add indication for 2-level lumbar disc arthroplasty when using a 2-level FDA-approved implant
- Lumbar discectomy – remove exclusion for annular closure devices (note: medical necessity of the implant is determined by health plan medical policy)
- Lumbar fusion – remove exclusion for anterior lumbar interbody fusion for indirect lumbar decompression in the absence of instability
- Cervical decompression with or without Fusion – add criteria for when revision or replacement may be medically necessary
- Cervical disc arthroplasty – add criteria for when revision or replacement may be medically necessary
- Two-level cervical disc arthroplasty – add indication for second level arthroplasty when prior arthroplasty already performed
- Lumbar disc arthroplasty – add requirement to manage underlying psychiatric disorder; add contraindications including prior fusion, poorly managed psychiatric disorder, chronic radiculopathy; add exclusion for prior lumbar fusion
- Scheurmann’s kyphosis – removed “associated neurological deficits” as a clinical consideration
- Scoliosis – expand indication to include thoracic for progressive adolescent idiopathic scoliosis; increased Cobb angle for skeletally mature patients to greater than 50 degrees
- Spinal stenosis – require surgeon’s interpretation of flexion-extension lateral spine x-ray documented in the medical record; added indications for recurrent stenosis, adjacent-level stenosis after a prior fusion, and planned indirect decompression via anterior approach decompression via anterior approach
Joint surgery:
- Total shoulder arthroplasty – add fracture indication for total shoulder arthroplasty (although reverse total shoulder arthroplasty is preferred) to align with AAOS feedback
- Total shoulder arthroplasty – add exception for Kellgren-Lawrence grade 4 to be consistent with total knee and total hip arthroplasty
- Hemiarthroplasty – added indications for hemiarthroplasty for glenohumeral arthritis with irreparable rotator cuff and for malignancy involving the glenohumeral joint or surrounding soft tissue
- Reverse shoulder arthroplasty – add indication when glenoid bone stock inadequate to support anatomic glenoid prosthesis
- Labrum repair – remove requirement that MRI-demonstrated SLAP lesion is traumatic in nature
- Adhesive capsulitis – match requirements in knee arthroscopy; reduce timeframe of conservative management to 6 weeks post-surgery for lysis of adhesions/capsular release and MUA
- Total knee arthroplasty – add patellofemoral osteoarthritis as an indication for total knee arthroplasty
- Knee arthroscopy – new indication for abrasion arthroplasty/microfracture
- Knee/arthroscopically assisted lysis of adhesions – remove 12-week post-surgery requirement
- Knee/manipulation under anesthesia – remove 12-week post-surgery requirement
- Treatment of osteochondral defects – remove BMI 35 or less from patient selection criteria
- Autologous chondrocyte implantation – Added contraindications from MACI package insert, including severe osteoarthritis, inflammatory joint disease, knee surgery other than biopsy or MACI preparation, and inability to cooperate with postoperative rehab program
Small joint surgery:
- Hallux rigidus – add criteria for select implant arthroplasties in great toe; remove exclusion for percutaneous osteotomy
- Hallux valgus/bunionette – remove exclusion for implant arthroplasties
- Lesser toe deformities – remove exclusions for implant arthroplasties and intramedullary fixation devices
- First metatarsophalangeal joint arthrodesis – remove requirement for 6 months of symptoms
- First metatarsophalangeal joint arthroplasty – new indication
- Hallux rigidus/exclusions – clarified specific types of excluded implants; excluded metatarsophalangeal joint arthroplasties for any other indications; excluded peripheral neuropathy/Charcot joint
Sacroiliac joint (SU) fusion:
- Expand indication to include any FDA-approved minimally invasive/percutaneous SI joint fusion device with fixation
- Require a trial of at least one therapeutic intra-articular SI joint injection
- New criteria for revision minimally invasive SI joint fusion
- Add exclusion for posterior (dorsal) minimally invasive SI joint fusion procedures using only bone grafts and no internal fixation device
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 at 866-714-1107, Monday–Friday, 8 a.m.–5 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.
In the February 2021 issue of Provider News, we announced a new reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services which states that Anthem does not allow reimbursement for office evaluation and management services when reported with revenue code 761.
Beginning with dates of service on or after September 1, 2022, Anthem will expand the current policy to include two additional revenue codes (760 and 769).
For specific policy details, visit the Reimbursement Policies page at anthem.com.
Effective September 1, 2022, AIM Specialty Health® (AIM), a separate company, will expand the AIM Musculoskeletal Program to perform medical necessity review of the requested site of service for certain spine, joint and interventional pain procedures for Anthem fully-insured members, as outlined below.
AIM will continue to manage the AIM Musculoskeletal program and level of care review. The AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). AIM will use the following Anthem Clinical UM Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The clinical criteria to be used for these reviews can be found on Anthem’s Clinical UM Guidelines page. Please note, this does not apply to procedures performed on an emergent basis.
A subset of the AIM Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT codes requiring prior authorization for the AIM Musculoskeletal site of care program is available on the AIM Musculoskeletal microsite. To determine if prior authorization for the AIM Musculoskeletal Program applies to an Anthem member on or after September 1, 2022, contact the Anthem Provider Services phone number on the back of the member’s ID card. AIM will recognize out of scope membership and will not require prior authorization for such members. Note: If a provider office attempts to use the Interactive Care Reviewer (ICR) tool on the Availity Portal to prior authorize an outpatient musculoskeletal case, ICR will produce a message referring the provider to AIM. (ICR cannot accept prior authorization requests for services administered by AIM.)
Members included in the new program
All fully-insured members currently participating in the AIM Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the AIM Musculoskeletal Program to add to their members’ benefit package as of September 1, 2022. The following members are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and the Federal Employee Program® (FEP®).
Prior authorization requirements
For services scheduled to begin on or after September 1, 2022, providers must contact AIM to obtain prior authorization. Ordering and servicing providers may begin contacting AIM on August 15, 2022.
Providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortallSM directly at www.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 www.availity.com.
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday–Friday, 8 a.m.–5 p.m.
Initiating a request on AIM’s ProviderPortalSM and entering all the requested clinical questions will allow you to receive an immediate determination. The AIM Musculoskeletal Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM musculoskeletal training webinars
We invite you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to the AIM Musculoskeletal microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Effective October 1, 2022, AIM Specialty Health® (AIM), a separate company, will enhance the AIM Musculoskeletal program by adding a monitored anesthesia care (MAC) for interventional pain component to perform medical necessity review of monitored anesthesia, or conscious sedation, when performing certain interventional pain procedures for Anthem fully-insured members, as outlined below.
Prior authorization will now be required for the clinical appropriateness of monitored anesthesia services when the pain management clinician requests the monitored anesthesia services in conjunction with interventional pain codes. It is the obligation of the requesting provider to have available Anthem’s determination for the anesthesiologist on the day of the procedure. AIM will use the following Anthem Clinical UM Guideline: CG-Med-78: Anesthesia Services for Interventional Pain Management Procedures. The clinical criteria to be used for these reviews can be found on Anthem’s Clinical UM Guidelines page. Clinical site of care may also be applicable if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center (ASC). If you have a member in a current course of treatment for pain management where we approved without reviewing the MAC, please identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.
At this time, the codes to be reviewed are 01991, 01992, 01937, 01938, 01939 and 01940. A complete list of CPT codes requiring prior authorization for the AIM Monitored Anesthesia Care for Interventional Pain program is available on the AIM Musculoskeletal microsite. To determine if prior authorization is needed for an Anthem member on or after October 1, 2022, contact the Anthem Provider Services phone number on the back of the member’s ID card. AIM will recognize out of scope membership and will not require prior authorization for such members. Note: If providers attempt to use the Interactive Care Reviewer (ICR) tool on the Availity Portal to prior authorize an outpatient musculoskeletal procedure, ICR will produce a message referring the provider to AIM. (ICR cannot accept prior authorization requests for services administered by AIM.)
Members included in the new program
All fully-insured members currently participating in the AIM Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the AIM Musculoskeletal program to add to their members’ benefit package as of October 1, 2022. The following members are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and the Federal Employee Program® (FEP®).
Prior authorization requirements
For interventional pain procedures that are scheduled to begin on or after October 1, 2022, all providers must contact AIM to obtain prior authorization. Ordering and servicing providers may begin contacting AIM on September 17, 2022.
Providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortallSM directly at www.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 www.availity.com.
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday–Friday, 8 a.m.–5 p.m.
Initiating a request on AIM’s ProviderPortalSM and entering all the requested clinical questions will allow you to receive an immediate determination. The AIM Musculoskeletal Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM Musculoskeletal training webinars
Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to the AIM Musculoskeletal microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Effective June 1, 2022, the Blue Cross Blue Shield Service Benefit Plan, aka Federal Employee Program (FEP), will be changing the process for responses to third-party requests for correspondence for claim processing. Currently, Anthem sends correspondence to the third-party biller who requested the information. Effective June 1, 2022, responses to correspondence requests received from third-party billers will be mailed to the servicing provider office to align with internal Anthem policy directives.
Questions can be directed to the FEP Customer Service team at 800-522-5566.
Specialty pharmacy updates for Anthem are listed below.
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), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after September 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our clinical criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0214
|
Carvykti (ciltacabtagene autoleucel)
|
C9399, J3490, J3590
|
|
ING-CC-0200
|
Aduhelm (aducanumab-avwa)
|
J0172
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Beginning July 1, 2022, the State of Connecticut Employer Group is expanding the number of specialties eligible to be tiered.
There will be two (2) tiers (cost share levels) for members of the State of Connecticut Employer Group networks. In addition to allowing these members to use different tiered levels of primary care providers (PCPs), the following expanded list of specialties will also be tiered:
|
· Family practice
|
· Pulmonary disease
|
|
· Internal medicine
|
· Gastroenterology
|
|
· General practice
|
· Otolaryngology
|
|
· Pediatric medicine
|
· Cardiac electrophysiology
|
|
· Cardiology
|
· Neurology
|
|
· Orthopedic surgery
|
· Allergy immunology
|
|
· Psychiatry
|
· Urology
|
|
· Obstetrics gynecology
|
· Colorectal surgery
|
|
· Endocrinology
|
· Dermatology
|
|
· Emergency medicine
|
· Nephrology
|
|
· General surgery
|
· Ophthalmology
|
|
· Rheumatology
|
· Thoracic surgery
|
|
· Hematology/oncology
|
|
All other specialty care will not be tiered.
Members who receive services from PCPs or specialists that are designated as Value Tier 1 will have lower cost shares than those who receive the same services from PCPs or specialists that are Participating Tier 2. Value Tier 1 PCPs and specialists will continue to have an identifier in our provider directory.
The above applies to State BlueCare Prime, State Preferred, and State BlueCare networks. These changes only apply for State of Connecticut Employer Group members.
Updates specific to State of Connecticut BlueCare Prime Tiered Network ONLY
State of Connecticut Employer Group members who receive services from Value Tier 1 PCPs and specialists will have a $0 copay. Participating Tier 2 PCPs will have a $50 copay, and Participating Tier 2 specialists will have a $100 copay. Members who receive services from participating specialty care providers who are not tiered will have a $0 copay.
Referrals will no longer be required for State of Connecticut Employer Group members utilizing the State of Connecticut BlueCare Prime Tiered Network.
Sample of the new State of Connecticut BlueCare Prime tiered member ID card
State of Connecticut Employer Group and State Partnership Plan member ID number prefix list
|
Network Name
|
Product Type
|
State of Connecticut
|
State Partnership Plan
|
|
State Preferred
|
PPO
|
XGS
|
N/A
|
|
State BlueCare
|
HMO - Point of Service (PCP referral not required)
|
XGR
|
SHP
|
|
State BlueCare
|
HMO - Point of Enrollment (PCP referral not required)
|
XGT
|
N/A
|
|
State BlueCare
|
HMO - Point of Enrollment (PCP referral required)
|
XGL
|
N/A
|
|
State BlueCare Prime (Narrow Network)
|
HMO - Point of Service (PCP referral not required)
|
X6G
|
N/A
|
Effective with dates of service on or after September 1, 2022, Anthem will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.
Prior to payment, Anthem will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Anthem will reimburse using CPT code 99211.
Professional providers who 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 Provider Experience representative.
For services beginning on September 1, 2022, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) will be reviewed by myNEXUS.* Through this program, myNEXUS clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate, least restrictive environment.
How to submit or check a prior authorization request
For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests on Tuesday, August 30, 2022, for members whose anticipated discharge date is September 1, 2022, or after.
Providers are encouraged to request authorization using NexLync. Go to https://portal.mynexuscare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.
If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 8 a.m. to 8 p.m., Monday through Friday, or send a fax to myNEXUS at 833-311-2986.
Please note: myNEXUS will not review authorization requests for durable medical equipment (DME), ambulance, and other related services that do not fall under Medicare-covered home healthcare services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.
To learn more about myNEXUS and upcoming training webinars, visit www.myNEXUScare.com or email Provider_Network@myNEXUScare.com.
If you have additional questions, please call the myNEXUS Provider Call Center at 844-411-9622.
Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to September 1, 2022, should be directed to the health plan.
Effective for dates of service on and after September 11, 2022, the following updates will apply to the
AIM Specialty Health®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.
Updates by guideline
Imaging of the spine
- Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs
Imaging of the extremities
- Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture
- Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
- Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
- Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty
Vascular imaging
- Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios
- Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines
- Chronic stroke/TIA – New indication; modality approach by circulation presentation
- Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
- Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
- Stenosis or occlusion, extracranial carotid arteries – Post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
- Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
- Upper or lower extremity peripheral arterial disease (PAD):
- Suspected PAD without physiologic testing (including exercise testing) not indicated
- New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)
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 https://www.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 Portal* at https://www.availity.com
- Call the AIM Contact Center toll-free number Monday through Friday from 8 a.m. to 8 p.m.
- Connecticut: 833-305-1811
- Maine: 833-775-1954
- New Hampshire: 833-342-1261
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.
|