March 2019 Anthem Connecticut Provider Newsletter

Contents

AdministrativeCommercialMarch 1, 2019

Explore updates to medical attachment tool

AdministrativeCommercialMarch 1, 2019

HEDIS® 2019: Controlling High Blood Pressure

AdministrativeCommercialMarch 1, 2019

Please be sure to notify us of changes to your practice

AdministrativeCommercialMarch 1, 2019

EDI Gateway migration updates

AdministrativeCommercialMarch 1, 2019

Digital Provider Enrollment application now available

AdministrativeCommercialMarch 1, 2019

Additional changes to anthem.com to launch in March

AdministrativeCommercialMarch 1, 2019

Pathway Network Clarifications

AdministrativeCommercialMarch 1, 2019

Sign up today for provider eUpdates

PharmacyCommercialMarch 1, 2019

Pharmacy information available on anthem.com

PharmacyCommercialMarch 1, 2019

Commercial drug list important updates

PharmacyCommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy

State & FederalMedicare AdvantageMarch 1, 2019

Keep up with Medicare news

State & FederalMedicare AdvantageMarch 1, 2019

Clinical criteria updates for specialty pharmacy

State & FederalMedicare AdvantageMarch 1, 2019

Change to 835 ERA for all D-SNP MA members for 2019

State & FederalMedicare AdvantageMarch 1, 2019

Dual eligible special needs plans: provider training required

AdministrativeCommercialMarch 1, 2019

Explore updates to medical attachment tool

Have you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You’ll now find these changes that were recently introduced:

 

  • Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim.
  • To send a solicited attachment, now find the ‘Send Attachment’ link on the top, right side of the page.
  • Expanded file size – each attachment can now be up to 40 MB with a total of 80 MB as the file size limit.

 

If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.

 

How to access/setup the solicited medical attachments tool for your office

Availity Administrators must complete these steps:

  1. From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, follow the prompts and complete the following sections:
  2. Select Application > choose Medical Attachments Registration
  3. Provider Management > Select Organization from the drop-down. Add NPIs and/or tax IDs. (Multiples can be added separated by spaces or semi-colons.)
  4. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name.

 

Submitting medical attachments

Once the above setup is completed, Availity Users will complete these steps:

  1. Log in to www.availity.com
  2. Select Claims and Payments > Attachments-New > Send Attachment Tab
  3. Complete all required fields of the form
  4. Attach supporting documentation
  5. Submit

               

Need training?

To access additional training for this Availity feature:

  1. Log in to the Availity Portal at www.availity.com
  2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
  3. In the new window a list of available topics will open. Locate and click Medical Attachments.
  4. Under the Recordings section, click View Recording

AdministrativeCommercialMarch 1, 2019

Clinical practice and preventive health guidelines available on anthem.com

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

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Practice Guidelines.

 

AdministrativeCommercialMarch 1, 2019

HEDIS® 2019: Controlling High Blood Pressure

One of the measures we report on is Controlling High Blood Pressure (CBP). This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).

 

What’s new for 2019?

  • The CBP measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
  • If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
  • Compliant BP is defined as <140/90 mm Hg for all members.
  • Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the provider can be utilized for the measure.

 

What do we need from you?

We need the last two (2) office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018, please send that documentation as well.

 

Common chart deficiencies

  • Recheck elevated blood pressures readings and document all BP readings in the medical record.

 

For more information on HEDIS visit anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Select Health & Wellness tab from the blue bar at the top of the page > Quality Improvement and Standards > HEDIS Information.

 

Thank you for your continued cooperation and support of HEDIS.

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

AdministrativeCommercialMarch 1, 2019

Appointment access standards for PCPs, specialty care and behavioral health practitioners

As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. Please visit anthem.com to access our Provider Manual for our guidelines on access to care for primary care practitioners (PCPs), specialty care practitioners (SCPs) and behavioral health practitioners (BHPs). We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

 

  1. Assessing the availability of appointments via phone calls by our staff or designated vendor to the provider’s office
  2. Analysis of member complaint data
  3. Analysis of member satisfaction surveys

 

The following information is excerpted from the Provider Manual for your review:

 

Physician/provider access goals and calendar requirements

One of our goals is to make accessing medical care easy for members by assuring a comprehensive network of physicians and providers close to their homes.  As a result, we have implemented the following plan-wide geographic access goals as guidelines for our network.  It is our goal to provide members with access to the following within our defined service areas:

 

  • Two PCPs within five miles of each member
  • Two OB/GYNs within eight miles of each member
  • Full range of specialists (including non-MD allied providers) within 15 miles of each member

 

Calendar access requirements

  • Primary care providers:
    • Preventive care - members scheduling periodic routine exams (well care/preventive visits), appointments should be available within 45 calendar days of a member’s call. Care provided to prevent illness or injury; examples include, but are not limited to, routine physical examinations, immunizations, mammograms and pap smears.
    • Urgent care appointment with acute symptoms - appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.
    • Routine care with symptoms – must have access to care within five (5) days of the member’s call.
    • Routine check-up – must have access to care within 10 business days of the member’s call.  This consists of care provided for non-symptomatic visits or follow-up.

 

Though it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs.  As a reminder, we now contract with walk-in centers and urgent care facilities which are listed in our directory.

 

  • Specialists:
    • Urgent care appointment with acute symptoms - appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.
    • Routine check-up – must have access to care within 15 calendar days of the member’s call.  Care provided for non-symptomatic visits for health check.

 

  • Behavioral health providers:
    • Non-life threatening emergency needs - must be seen, or have appropriate coverage directing the member, within six (6) hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms and needs immediate attention; no risk of loss of life.
    • Urgent needs - must be seen, or have appropriate coverage directing the member, within 48 hours. Non-emergent behavioral health illness that requires immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.
    • Initial routine office visit - must be seen within 10 business days. New patient non-urgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.
    • Follow-up routine visit – must be seen within 30 calendar days.  Non-urgent behavioral health care; member has been scheduled for a non-urgent consultation or requires services including, but not limited to, follow-up and existing medication management.

 

After-hours coverage

After-hours coverage, which is required by the Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent services outside of regular office hours.  Note that telephone answering machines and voice mail are not acceptable means of providing access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911. The recording or live person must refer the patient to urgent care center, 911, or emergency room, and also provide the option to contact a live health care practitioner (via cell, pager, beeper, transfer system) , get a call back for urgent instructions, or be transferred directly to the available practitioner or on-call practitioner.

 

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document and we understand the reasons that the requirements are not met.

AdministrativeCommercialMarch 1, 2019

Please be sure to notify us of changes to your practice

It is very important that all provider demographic information is accurate and up to date in our systems. We receive a significant number of claims with a name or address that does not match our provider files, and this can result in a claim payment to an incorrect provider or a claim denial. In addition, our members frequently utilize the online provider directories to obtain information regarding our network of participating providers, and having accurate information is essential. Please be sure to notify us of all changes such as:

 

  • Telephone number for members to schedule appointments at your practice location
  • Practice location address
  • Provider name
  • Practice name
  • Providers terminating or leaving your practice
  • Providers joining your practice
  • PCPs changing status to or from accepting new patients or not accepting new patients
  • Billing address
  • Tax ID number
  • Specialty
  • Hospital admitting privileges

 

How to access the online Provider Maintenance Form:

Visit anthem.com > select Providers, then from the drop-down menu under Provider Resources, select Provider Maintenance.  Follow the instructions provided to update and submit the new information.

 

If you have not previously accessed anthem.com and established your state as Connecticut, you will first need to select Providers > Provider Overview, then select Connecticut.  The website will subsequently default to Connecticut as your state.

 

Advance notice of provider demographic and/or practice changes is required; retroactive changes are not allowed. Requests must be received 30 days prior to the change/update. Any request received with less than 30 days advance notice may be assigned a future effective date. Please provide 90 days advance notice of termination from our network; however, your specific contract provisions may supersede this. Check your contract for any specified requirements regarding length of notice required in advance of your termination request.

AdministrativeCommercialMarch 1, 2019

EDI Gateway migration updates

We have designated Availity to operate and serve as your electronic data interchange (EDI) entry point, also called the EDI Gateway. The EDI Gateway is a no-cost option for providers that choose to submit their own EDI claims to us. If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.

 

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway. 

 

Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.  

 

  • Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.

 

If you wish to become a direct a trading partner with Availity, the setup is easy.

 


Need assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

 

835 Electronic Remittance Advice (ERA)

Please use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes. Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.

 

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

 

If you have any questions, contact Availity Client Services at 1-800-Availity (800-282-4548), Monday – Friday, 8:00 a.m. to 7:30 p.m.

AdministrativeCommercialMarch 1, 2019

Digital Provider Enrollment application now available

We continue to make it easier and more convenient to become an Anthem participating provider. The Digital Provider Enrollment application has been designed to speed up the enrollment process, allow providers to submit data at one time, and obtain real-time updates on the status of an application.

 

Access to the new application is available through Availity, our secure web-based provider portal.

New and current Availity users should ensure their user ID has the correct access. Please ensure that you have been assigned to Provider Enrollment.

 

Digital provider enrollment offers many benefits:

  • Supports enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with us.
  • New individual providers or groups can request a contract.
  • Existing groups can add providers to their existing contract.
  • Providers can check the status of an application in real-time using the enrollment dashboard.

 

To use the new Digital Enrollment application, please ensure your provider data on CAQH is current and in a complete or re-attested status, then log into Availity and use the following navigation: Choose your state > Payer Spaces > Provider Enrollment.

AdministrativeCommercialMarch 1, 2019

Commercial Risk Adjustment Program update: Medical chart collection for ACA members due March 31, 2019

Each year, we request your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented hierarchical condition categories (HCC), in order to document and close the coding gaps. 

 

The CRA Program is specific to our Affordable Care Act (ACA) members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

 

With our Retrospective Program we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS). This particular effort is part of our compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Anthem network providers, including PCPs, specialists, facilities, behavioral health, ancillary, etc., may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. The vendors’ web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. 

 

We ask that our network providers submit the medical record information to the designated vendor within 30 days of the request (no later than March 31, 2019).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

 

  • EMR Interoperability
    • Allscripts (Opt in -- signature required)
    • NextGen (Opt out -- auto-enrolled)
    • Athenahealth (Opt out -- auto-enrolled)
    • MEDENT
  • Remote/direct Anthem access
  • Vendor virtual or onsite visit
  • Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for our network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact Alicia Estrada, our Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.  

 

AdministrativeCommercialMarch 1, 2019

Additional changes to anthem.com to launch in March

This March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms. A sample screen image of the upcoming changes is attached to this article. 

This first version of the new Provider Forms will keep growing and evolving in the coming months.

 

We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes.

ATTACHMENTS (available on web): Provider Forms and Guidelines.jpg (jpg - 0.13mb)

AdministrativeCommercialMarch 1, 2019

Pathway Network Clarifications

Prior to January 1, 2019, Anthem had provider networks unique to our HMO and PPO small group and individual plan products sold on the State of Connecticut’s Health Insurance Exchange, Access Health CT (the “Exchange”).These networks were called the Pathway Networks, and were also sometimes referred to as our “Exchange Networks” or “On-Exchange Networks.”  

 

Beginning January 1, 2019, the Pathway Networks will also support small group and individual products sold by us outside of the Exchange direct to customers. 

 

What this means for you:

As of January 1, 2019, all of our individual and small group products whether sold on the Exchange or by us outside of the Exchange will be supported by the Pathway networks. For individual members, this change is effective as of January 1, 2019. For small group members, this change is effective upon the date of their 2019 renewal (e.g., for small groups that renew February 1, this change will be effective February 1, for small groups renewing March 1, this change will be effective March 1, etc.). Once effective, individual and small group customers must obtain services from providers participating in the Pathway networks in order to receive in-network benefits. 

 

Specifically, as of the applicable dates indicated above, all individual and small group members must use the following networks to receive the in-network level of benefits:

 

  • Members of all Anthem small group HMO Plan products must use the Pathway CT HMO Network.
  • Members of all Anthem individual HMO Plan products must use the Pathway Enhanced Network.
  • Members of all Anthem small group PPO Plan products must use the Pathway CT PPO Network.
  • Members of all Anthem individual PPO Plan products must use the Pathway Network.

 

Providers who participate in Anthem networks need to be aware of the following:

 

  • Compensation applicable to all Anthem small group products, whether on or off exchange, has always been the same. This did not change as of January 1, 2019. 

 

  • As of the dates indicated above, providers participating in Anthem networks must participate in the applicable Pathway Network(s) to render health care services on an in-network basis to members of Off-Exchange Plan products. In-network compensation for covered health care services rendered to these members will be the amount(s) corresponding to the applicable Pathway Network(s).

 

  • All Anthem individual members have been advised in their renewal packet of the changes and the need to check our provider directory to confirm participation of their health care providers in the network supporting the plan products they enroll in. All Anthem small group employers have been (or will be) advised of the changes and the need for their employees to confirm participation of their health care providers in the network supporting their plan.

 

More detail on these changes, including product names and prefixes, can be found on our 2019 Individual & Small Employer Group Health Plans Quick Reference Guide.  If you have any questions, please contact your Provider Relations Representative or e-mail our Provider Relations Department at: CTNetworkManagement-SM@anthem.com.

 

Thank you for your continued service and dedication to all our members.

AdministrativeCommercialMarch 1, 2019

Sign up today for provider eUpdates

Connecting with Anthem and staying informed is easy, fast and convenient with our provider eUpdates.  eUpdates feature short topic summaries on late breaking news that impacts providers such as:

 

  • Website updates
  • System changes
  • Policy updates
  • Claims and billing updates
  • And more…..

 

Registration is fast and easy. There is no limit to the number of subscribers who can register for our eUpdates, so your facility or practice can submit as many email addresses as you like.  Sign up today!

PharmacyCommercialMarch 1, 2019

Some of your patients will begin moving to IngenioRx in Q2 2019

In January, Anthem, Inc. announced that it’s accelerating the launch of IngenioRx, its new pharmacy benefits manager (PBM), which will serve members of all Anthem’s affiliated health plans. We will begin moving some members to IngenioRx in Q2, and we will continue the transition, in waves, with the majority of members moving in the latter part of 2019 and Q1 2020.

 

As one of our contracted providers, we wanted to share a few details about what this means for you.

 

  • If your patient has an active prior authorization it will transfer to IngenioRx.
  • If your patient currently fills home delivery or specialty prescriptions through Express Scripts, prescriptions with at least one refill will be transferred, with the exception of controlled substances and compound drugs, to IngenioRx Home Delivery Pharmacy and IngenioRx Specialty Pharmacy.
  • As your patients transition, new home delivery and specialty prescriptions will need to be sent to IngenioRx.
    • For providers using ePrescribing there are no changes, simply select IngenioRx.
    • For providers who do not use ePrescribing, you should send your home delivery and specialty prescriptions to IngenioRx.

      IngenioRx Home Delivery Pharmacy new prescriptions:
      Phone Number: 833-203-1742
      Fax number: 800-378-0323

      IngenioRx Specialty Pharmacy:
      Prescriber phone: 833-262-1726
      Prescriber fax: 833-263-2871

 

  • If you want to check whether or not a specific patient has moved to IngenioRx, Availity will display the member’s PBM information under the patient information section as part of the eligibility and benefits inquiry.
  • If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s ID card or call the number you normally use for questions.

PharmacyCommercialMarch 1, 2019

Pharmacy information available on anthem.com

For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions and other requirements, restrictions or limitations that apply to certain drugs, visit anthem.com/pharmacy information. The commercial and marketplace drug lists are reviewed and updates are posted to the website quarterly (the first of the month for January, April, July and October). 


To locate the commercial drug list, visit anthem.com/pharmacy information, scroll down to Drug List Management and select 'Review our Commercial Drug Lists'. 

To locate the Marketplace Select Formulary and pharmacy information, go to anthem.com/pharmacy information, scroll down to Drug List Management, select 'Review our Commercial Drug Lists', then scroll down to Select Drug Lists and select 'Connecticut Select Drug List'. 

 

Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.

PharmacyCommercialMarch 1, 2019

Commercial drug list important updates

Effective with dates of service on and after April 1, 2019, and in accordance with our Pharmacy and Therapeutic (P&T) process, we will update our commercial drug lists. Updates may include changes to drug tiers or the removal of a drug.

 

To help ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a preferred drug to patients currently using a non-preferred drug, if appropriate.

 

Please note, this update does not apply to the Select Drug List or drugs lists utilized by the Federal Employee Program (FEP).

 

To view a summary of changes, click here.

PharmacyCommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy

On December 1, 2018, we introduced the new clinical criteria page for injectable, infused or implanted drugs. Effective for dates of service on and after March 1, 2019, the following new clinical criteria will be included in our clinical criteria review process. The drugs that require prior authorization will continue to require prior authorization notification with AIM. 

 

Existing precertification requirements have not changed for the specific clinical criteria below. While there are no material changes, the document number and online location has changed. To access the clinical criteria information please click here. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical Guideline/Medical Policy.

 

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

 

Clinical Guideline/ Medical Policy

Clinical Criteria Document Number

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

CG-DRUG-29

ING-CC-0006

Hyaluronan Injections

Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synvisc/-One, TriVisc, Visco-3

J7318, J7320 , J7321, J7322, J7323, J7324 , J7325, J7326, J7327, J7328, J7329

DRUG.00015

ING-CC-0007

Synagis (palivizumab)

Synagis

90378

DRUG.00031

ING-CC-0008

Testopel (testosterone subcutaneous implant)

Testosterone implant

S0189

DRUG.00074

ING-CC-0009

Lemtrada (alemtuzumab)

Lemtrada

J0202

DRUG.00078

ING-CC-0010

Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors

Praluent, Repatha

J3490 , J3590

DRUG.00095

ING-CC-0011

Ocrevus (ocrelizumab)

Ocrevus

J2350

DRUG.00099

ING-CC-0012

Brineura (cerliponase alfa)

Brineura

J0567

DRUG.00116

ING-CC-0013

Mepsevii (vestronidase alfa)

Mepsevii

J3490

CG-DRUG-03

ING-CC-0014

Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

Avonex, Plegridy, Rebif, Betaseron, Extavia, Copaxone, Glatopa

J1595, J1826, J1830, J3490, Q3027, Q3028

CG-DRUG-27

ING-CC-0017

Xiaflex (clostridial collagenase histolyticum) injection

Xiaflex

J0775

CG-DRUG-28

ING-CC-0018

Lumizyme (alglucosidase alfa)

Lumizyme

J0221

CG-DRUG-43

ING-CC-0020

Tysabri (natalizumab)

Tysabri

J2323

CG-DRUG-54

ING-CC-0021

Fabrazyme (agalsidase beta)

Fabrazyme

J0180

CG-DRUG-55

ING-CC-0022

Vimizim (elosulfase alfa)

Vimizim

J1322

CG-DRUG-56

ING-CC-0023

Naglazyme (galsulfase)

Naglazyme

J1458

CG-DRUG-57

ING-CC-0024

Elaprase (idursufase)

Elaprase

J1743

CG-DRUG-58

ING-CC-0025

Aldurazyme (laronidase)

Aldurazyme

J1931

CG-DRUG-73

ING-CC-0027

Denosumab agents

Prolia, Xgeva

J0897

CG-DRUG-84

ING-CC-0028

Benlysta (belimumab)

Benlysta

J0490

CG-DRUG-88

ING-CC-0029

Dupixent (dupilumab)

Dupixent

J3490, J3590

CG-DRUG-89

ING-CC-0030

Implantable and ER Buprenorphine Containing Agents

Probuphine, Sublocade

J0570, J3490 , Q9991, Q9992

CG-DRUG-103

ING-CC-0032

Botulinum Toxin

Botox, Xeomin, Dysport, Myobloc

J0585, J0586, J0587 , J0588 , J0585, J0586 , J0587 , J0588

CG-DRUG-104

ING-CC-0033

Xolair (omalizumab)

Xolair

J2357

CG-DRUG-108

ING-CC-0035

Duopa (carbidopa and levodopa enteral suspension)

Duopa

J7340

CG-DRUG-111

ING-CC-0037

Kanuma (sebelipase alfa)

Kanuma

J2840

CG-DRUG-112

ING-CC-0038

Human Parathyroid Hormone Agents

Tymlos

J3490

DRUG.00013

ING-CC-0039

GamaSTAN [(immune globulin (human)]

GamaSTAN. GamaSTAN S/D

J1460, J1560

DRUG.00027

ING-CC-0040

Prialt (ziconotide)

Prialt

J2278

DRUG.00050

ING-CC-0041

Soliris (eculizumab)

Soliris

J1300

DRUG.00077

ING-CC-0042

Monoclonal Antibodies to Interleukin-17

Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)

C9399, J3490, J3590

DRUG.00080

ING-CC-0043

Monoclonal Antibodies to Interleukin-5

Cinqair (reslizumba), Fasenra (benralizumab), Nucala (mepolizumab)

J0517, J2182, J2786

DRUG.00081

ING-CC-0044

Exondys 51 (eteplirsen)

Exondys 51

J1428

DRUG.00086

ING-CC-0045

Increlex (mecasermin)

Increlex

J2170

DRUG.00090

ING-CC-0046

Zinplava (bezlotoxumab)

Zinplava

J0565

DRUG.00096

ING-CC-0047

Trogarzo (ibalizumab-uiyk

Trogarzo

J1746

DRUG.00104

ING-CC-0048

Spinraza (nusinersen)

Spinraza

J2326

DRUG.00108

ING-CC-0049

Radicava (edaravone)

Radicava

J1301

DRUG.00111

ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Ilumya, Tremfya

J1628, J3245

CG-DRUG-08

ING-CC-0051

Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

J1786 , J3060 , J3385

CG-DRUG-44

ING-CC-0057

Krystexxa (pegloticase)

Krystexxa

J2507

CG-DRUG-45

ING-CC-0058

Octreotide Agents

Sandostatin, Sandostatin LAR Depot

J2353 , J2354

CG-DRUG-61

ING-CC-0061

GnRH Analogs for the treatment of non-oncologic indications

Zoladex, Supprelin LA, Lupron Depot/Depot-Ped, Lupaneta Pack, Synarel Nasal Spray, Triptodur

C9399, J3490, J1675, J1950, J3315, J3316, J9202 , J9217, J9218 , J9225, J9226 , J3490

CG-DRUG-69

ING-CC-0063

Stelara (ustekinumab)

Stelara

J3357, J3358

CG-DRUG-74

ING-CC-0064

Interleukin-1 Inhibitors

Arcalyst, Ilaris

J2793, J0638

CG-DRUG-93

ING-CC-0066

Monoclonal Antibodies to Interleukin-6

Actemra, Kevzara

J3262, C9399 , J3490 , J3590

CG-DRUG-82

ING-CC-0067

Prostacyclin Infusion and Inhalation Therapy

Flolan, Remodulin, Tyvaso, Veletri, Ventavis

J1325, J3285, J7686, K0455 , Q4074, S0155 , S9347

CG-DRUG-83

ING-CC-0068

Growth hormone

Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive

J2940 , J2941 , Q0515 , S9558

CG-DRUG-85

ING-CC-0069

Egrifta (tesamorelin)

Egrifta

J3490

CG-DRUG-86

ING-CC-0070

Jetrea (ocriplasmin)

Jetrea

J7316

CG-DRUG-87

ING-CC-0071

Entyvio (vedolizumab)

Entyvio

J2503 , C9257, J9035, Q5107 , J2778, J0178

CG-DRUG-92

ING-CC-0073

Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

J0256, J0257

CG-DRUG-94

ING-CC-0075

Rituxan (rituximab) for Non-Oncologic Indications

Rituxan

J9311

CG-DRUG-95

ING-CC-0076

Nulojix (belatacept)

Nulojix

J0485

CG-DRUG-105

ING-CC-0078

Orencia (abatacept)

Orencia

J0129

CG-DRUG-109

ING-CC-0079

Strensiq (asfotase alfa)

Strensiq

J3490

PharmacyCommercialMarch 1, 2019

Specialty pharmacy clinical site of care program important reminder

AIM Specialty Health® (AIM), a separate company, administers the specialty pharmacy clinical site of care program. Based on the information you provide, AIM will review the drug for both clinical appropriateness and the site of care against health plan clinical criteria when services are requested in the hospital outpatient facility setting. It is important to note that coverage for the site of care is documented within the approved pre-certification.

If you need to request a change to the site of care previously approved, please contact AIM at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m. View the Clinical Site of Care drug list and Clinical Site of Care pre-service clinical review FAQs for more information.

 

State & FederalMedicare AdvantageMarch 1, 2019

Keep up with Medicare news

State & FederalMedicare AdvantageMarch 1, 2019

Clinical criteria updates for specialty pharmacy

The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

 

Clinical criteria effective date

Clinical criteria number

Clinical criteria

Clinical criteria (new/revised)

May 1, 2019

ING-CC-0001

Erythropoiesis Stimulating Agents

Revised

May 1, 2019

ING-CC-0004

H.P. Acthar Gel®

(repository corticotropin injection)

Revised

May 1, 2019

ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised

 

75743MUPENMUB 01/24/2019

State & FederalMedicare AdvantageMarch 1, 2019

Introducing a new clinical criteria web page for injectable, infused or implanted drugs covered under the medical benefit

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

 

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

 

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

 

If you have questions or feedback, please contact us.

State & FederalMedicare AdvantageMarch 1, 2019

Change to 835 ERA for all D-SNP MA members for 2019

We updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

 

  • Group code patient responsibility (PR) will be assigned.
  • Claim adjustment reason codes (CARCs) will include the following:
    • 1 — deductible amount (professional claim)
    • 2 — coinsurance amount (professional claim)
    • 3 — copay amount (professional and facility claim)
    • 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
    • 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
  • Remittance advice remark codes (RARCs) will include the following:
    • N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
    • N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
    • N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.

 

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

75743MUPENMUB 01/24/2019

State & FederalMedicare AdvantageMarch 1, 2019

Dual eligible special needs plans: provider training required

In 2019, we are offering dual eligible special needs plans (D-SNPs) to individuals who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs). D-SNPs provide enhanced benefits to individuals eligible for both Medicare and Medicaid. These plans are $0 premium plans. Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments. Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

 

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

 

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.

For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

75743MUPENMUB 01/24/2019