 Provider News ConnecticutMay 2022 Anthem Connecticut Provider NewsChange Healthcare will transition out of the post-payment hospital bill audit (HBA) program by the end of 2022. Effective immediately, Anthem’s complex and clinical audit (CCA) team will conduct the HBA program. For a short period of time, Change Healthcare may continue to contact you to finalize any work that is in process, or already scheduled.
Anthem continues to work with Cotiviti as a post-payment DRG validation audit partner. Effective immediately, the Anthem CCA team is assuming a larger role in conducting post-payment DRG validation audits and DRG readmission audits. In addition to receiving requests from Anthem’s CCA team, network-participating providers may continue to receive letters from Cotiviti requesting access to medical records for the purpose of conducting these audits. We will do our best to avoid duplicate medical record requests from Anthem and Cotiviti.
Thank you for your continued efforts to expedite medical record requests.
This notification applies to all lines of business and all markets. If you have questions about this notification, please contact your local Provider Call Center.
The annual PCP access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine care.
The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e., incorrect or non-working phone numbers, practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only or is no longer in practice; as well as staff refusing to participate in the survey. We ask that you update your office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.
Another item captured in the survey is open panel status for new patients. At the office level, we are capturing more closed panel data than is reflected in the provider directory for members. Please keep Anthem abreast of the open/close panel status of your practice.
What does this mean for our members? If the directory indicates “open” and the practitioner is not available for new patients, the member is making multiple calls to select a primary care physician. Their experience is reflected in the annual CAHPS® member survey of Anthem enrollees, which indicated “not open to new patients” as the number one reason throughout Anthem plans for not getting a personal doctor.
To be compliant, per the provider manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:
- Urgent – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within twenty-four (24) hours.
- Explanation – These callers are experiencing a non-emergent condition or injury with acute symptoms that require immediate attention (without prior authorization).
- Routine – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 10 business days.
- Explanation – A regular routine appointment is a non-symptom related visit for existing patients, such as a check-up, including physicals and chronic monitoring.
- Routine follow-up – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 30 calendar days.
- Explanation – This is for an evaluation of progress or services, including, but not limited to, medication management. This includes new or existing patients.
Note to staff: It is imperative that your office updates any changes to your practice using the online Provider Maintenance Form on anthem.com.
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 for 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:
- Assessing the availability of services via phone calls by our staff or designated vendor to the provider’s office
- Analysis of member complaint data
- Analysis of member satisfaction.
Providers are expected to make best efforts to meet these access standards for all members.
Here’s a quick reminder of our guidelines for PCPs:
- Preventive care – appointments for members scheduling periodic routine exams (well care/preventive visits) 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 services 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 – members must have access to care within 5 days of their call.
- Routine check-up – members must have access to care within 10 business days of their call. Care provided for non-symptomatic visits for health check.
- After-hours access – members must have access to care 24 hours a day, 7 days a week, 365 days a year. PCPs must arrange after-hours care to provide 24-hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.
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.
Here’s a quick reminder of our guidelines for SCP’s:
At this time these guidelines apply to certain specialties but could expand to other specialties in the future. To view those current impacted specialties, please view the access standards on anthem.com.
- Urgent care services 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 – members must have access to care within 15 business days of their call. Care provided for non-symptomatic visits for health check.
Here’s a quick reminder of our guidelines for BHPs:
- Non-life threatening emergency services – 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 services – must be seen, or have appropriate coverage directing the member, within 48 hours. Non-emergent behavioral health services that require immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.
- Initial routine services – 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 services – 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.
- BH follow-up appointment after discharge (inpatient psychiatric hospital release) – this standard is currently used for HEDIS ® Members must be seen within 7 calendar days. Members can be seen in office by their practitioner or another practitioner in the practice within the same timeframe.
- After-hours access – members must have access to care 24 hours a day, 7 days a week, 365 days a year. Must have arrangement for after-hours care to provide 24-hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.
After-hours urgent access coverage
After-hours coverage, which is required by the Participating Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent instructions outside of regular office hours. Note that telephone answering machines and voice mail are not acceptable means of providing urgent access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911.
Compliance requires that a recording or live person directs callers to urgent care, 911, the ER, or connects the call to the caller’s doctor or the doctor on call. In addition to these measures, but not in place of them, the messaging can give callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or an opportunity to ask for a call back for urgent questions or instructions.
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.
Submitting your updates in a timely manner helps to ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information in our online provider directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Online 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
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
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. We appreciate your help in keeping our online provider directories current.
These guidelines are developed to provide helpful information on how to report services to Anthem for the administration and observation of the drug Spravato®.
Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression. Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.
A main component in understanding how to report the administration of this drug is to identify whether the professional provider has purchased the drug for administration or whether the drug has been supplied and reported by a pharmacy. There are specific codes to report for each scenario:
Professional provider purchased and administered:
For professional providers that supply, administer, and provide the required observation of Spravato®, one of the following packaged service codes should be billed and should not include separate billing of the drug or the billing of the post-administration observation:
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HCPCS Code
|
Description
|
|
G2082
|
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
|
|
G2083
|
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
|
Note: When Spravato® is being supplied by the outpatient hospital and administered in an outpatient hospital, the facility should bill G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. In addition, there should not be a separate professional claim submitted as procedure codes G2082 and G2083 describe both the drug and the professional services.
Pharmacy supplied and professional provider administered:
When a pharmacy supplies Spravato® and is reporting this service in a separate claim, the drug should be billed with the HCPCS code, S0013 – Esketamine, nasal spray, 1 mg.
If the provider administering Spravato® did not purchase the drug, then the provider should not report the supply of the drug on their claim, as this will be reported by the pharmacy.
Post-administration observation:
When the provider does not bill a packaged service code (listed above), the professional provider may report an Evaluation and Management (E/M) service including the appropriate prolonged services code.
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CPT Codes
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Description
|
|
99202 - 99205
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Office or other outpatient visit for the evaluation and management of a new patient
|
|
99212 - 99215
|
Office or other outpatient visit for the evaluation and management of an established patient
|
|
99417
|
Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
|
In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding. Please refer to Anthem’s Prolonged Services – Professional Reimbursement Policy for additional information.
We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well. The COVID-19 pandemic has reignited public attention about the serious public health risks and consequences of disparities, and the critical need for health equity.
Health equity means everyone has the opportunity to reach their highest level of health, and barriers to doing so must be removed. Health disparities are health differences that are closely linked with social, economic, and/or environmental disadvantage.1 Achieving health equity requires focus on the elimination of barriers and disparities associated with factors such as race, ethnicity, gender, gender identity, religion, socioeconomic status, disability, and even where you live.2 As a result, it is imperative to offer access to care that is tailored to the unique needs of patients, and Anthem is committed to supporting our providers in this effort.
MyDiversePatients.com is where you can find resources, information, and techniques to help provide individualized care every patient deserves, regardless of their diverse backgrounds. There you can also find opportunities for free Continuing Medical Education (CME) credit for learning experiences on topics related to cultural competency and disparities. Mydiversepatients.com is free and accessible from any device (desktop computer, laptop, phone, or tablet) with no account or log in required. Scan the QR code below for direct access to mydiversepatients.com.
Stronger Together is a website where you can find free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created in collaboration with national organizations and are available for you to share with your patients and communities. Scan the QR code below for direct access to Stronger Together.
While there is no single, easy answer to address health care disparities, the vision of MyDiversePatients.com and Stronger Together is a start to reversing health care inequity one person at a time.
The total economic cost of alcohol use disorder has been estimated to be $249 billion according to the Centers for Disease Control and Prevention (CDC)1, $27 billion of which has been accounted for healthcare costs2. The CDC projects the economic impact to society is about $807 per person, per year.3
Alcohol use disorder also impacts the economy through work force disruptions caused by tardiness, absenteeism, employee turnover and conflict in the workplace. It causes a reduction in potential employees, customer and taxpayer bases.4
According to the CDC, alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015. This was more than all illicit substances combined. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost for the same period.
This chart shows the years of potential life lost (YPLL) related directly or indirectly to alcohol use disorder:
|
Cause
|
YPLL
|
|
Total YPLL
|
>2.7 million
|
|
100% alcohol attributed disease
|
684,750
|
|
Suicide
|
334,058
|
|
Motor vehicle crashes
|
323,610
|
|
Liver disease
|
202,391
|
|
Heart disease
|
118,021
|
|
Cancer
|
88,729
|
If you need assistance connecting your patients to opioid, substance use or alcohol use disorder treatment, contact your Anthem health plan.
Many resources are available for health professionals to support hypertension prevention and management and educate others. To support that effort, the Centers for Disease Control and Prevention (CDC)’s Division for Heart Disease and Stroke Prevention has put together these sets of educational materials for health professionals and patients:
Visit the Million Hearts® website for more resources designed for health professionals. Million Hearts® is a national initiative co-led by CDC and the Centers for Medicare & Medicaid Services (CMS). Million Hearts® aims to prevent 1 million heart attacks and strokes within five years.
Measure Up: Controlling High Blood Pressure (CBP) HEDIS® measure
The HEDIS measure Controlling High Blood Pressure (CBP) assesses adults ages 18–85 with a diagnosis of hypertension and whose blood pressure was properly controlled based on the following criteria:
- Adults 18–59 years of age whose blood pressure was <140/90 mm Hg
- Adults 60–85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
- Adults 60–85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg
Patient claims should include one systolic reading and one diastolic reading:
|
CPT II Code
|
Most recent systolic blood pressure
|
|
3074F
|
<130 mm Hg
|
|
3075F
|
130-139 mm Hg
|
|
3077F
|
≥ 140 mm Hg
|
|
CPT II Code
|
Most recent diastolic blood pressure
|
|
3078F
|
<80 mm Hg
|
|
3079F
|
80-89 mm Hg
|
|
3080F
|
≥ 90 mm Hg
|
When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.
Additional tips for talking to patients:
- Continue to educate patients about the risks of hypertension
- Encourage weight loss, regular exercise and diet
- Advise patients who are smoking to quit
- Talk about chronic stress and ways to cope with it in a healthy way
The following new and revised medical policies and clinical guidelines were endorsed at the February 17, 2022, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.
Medical policy updates
Revised medical policy effective February 24, 2022
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
Revised medical policies effective April 1, 2022
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
- GENE.00023 Gene Expression Profiling of Melanomas
- GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
- LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- SURG.00153 Cardiac Contractility Modulation Therapy
Revised medical policy effective April 1, 2022
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
Revised medical policy effective April 1, 2022
(The following policy was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- LAB.00015 Detection of Circulating Tumor Cells
Archived medical policy effective April 13, 2022
(The following policy has been archived and its contents have been transferred to a new Medical Policy and to an existing Clinical UM Guideline.)
- GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease [Note: Content for biomarker testing for Alzheimer's Disease moved to new medical policy LAB.00046 Biochemical Markers for Alzheimer's Disease. Content for gene testing for Alzheimer's Disease moved to CG-GENE-13 Genetic Testing for Inherited Diseases.]
Transitioned medical policy effective April 13, 2022
(The following policy was previously in another medical policy and has no significant changes.)
- LAB.00046 Biochemical Markers for Alzheimer's Disease [Note: Moved content related to biomarker testing for Alzheimer’s disease (AD) from GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.]
Revised medical policies effective April 13, 2022
(The following policies were revised to expand medical necessity indications or criteria.)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling [Note: Moved content for measurable residual disease testing to CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing]
- SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
Revised medical policies effective April 13, 2022
(The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
- DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
- DME.00032 Automated External Defibrillators for Home Use
- DME.00041 Low Intensity Therapeutic Ultrasound
- GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
- GENE.00038 Genetic Testing for Statin-Induced Myopathy
- GENE.00050 Gene Expression Profiling for Coronary Artery Disease
- GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
- GENE.00056 Gene Expression Profiling for Bladder Cancer
- LAB.00025 Topographic Genotyping
- LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
- LAB.00038 Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
- LAB.00039 Pooled Antibiotic Sensitivity Testing
- MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
- MED.00024 Adoptive Immunotherapy and Cellular Therapy
- MED.00053 Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00059 Idiopathic Environmental Illness (IEI)
- MED.00087 Optical Detection for Screening and Identification of Cervical Cancer
- MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
- MED.00102 Ultrafiltration in Decompensated Heart Failure
- MED.00104 Non-invasive Measurement of Advanced Glycation End Products (AGEs) in the Skin
- MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00111 Intracardiac Ischemia Monitoring
- MED.00112 Autonomic Testing
- MED.00118 Continuous Monitoring of Intraocular Pressure
- MED.00120 Gene Therapy for Ocular Conditions
- MED.00125 Biofeedback and Neurofeedback
- RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
- RAD.00044 Magnetic Resonance Neurography
- RAD.00052 Positional MRI
- RAD.00059 Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
- SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
- SURG.00053 Unicondylar Interpositional Spacer
- SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence
- SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
- SURG.00070 Photocoagulation of Macular Drusen
- SURG.00072 Lysis of Epidural Adhesions
- SURG.00075 Intervertebral Stabilization Devices
- SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation
- SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00113 Artificial Retinal Devices
- SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
- SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- SURG.00137 Focused Microwave Thermotherapy for Breast Cancer
- SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
- SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
- SURG.00149 Percutaneous Ultrasonic Ablation of Soft Tissue
- SURG.00150 Leadless Pacemaker
- SURG.00151 Balloon Dilation of the Eustachian Tubes
- SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
- SURG.00159 Focal Laser Ablation for the Treatment of Prostate Cancer
- TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
- TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation
- TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
- TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00037 Uterine Transplantation
New medical policies effective August 1, 2022
(The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- LAB.00043 Immune Biomarker Tests for Cancer
- LAB.00044 Saliva-based Testing to Determine Drug-Metabolizer Status
- LAB.00045 Selected Tests for the Evaluation and Management of Infertility
- RAD.00067 Quantitative Ultrasound for Tissue Characterization
- SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease
- TRANS.00038 Thymus Tissue Transplantation
Revised medical policy effective August 1, 2022
(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- SURG.00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema
Clinical guideline updates
Revised clinical guideline effective February 24, 2022
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
Revised clinical guidelines effective April 1, 2022
(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- CG-DME-06 Compression Devices for Lymphedema
- CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
Archived clinical guidelines effective April 13, 2022
(The following adopted clinical guidelines have been archived and their contents have been transferred to existing Clinical UM Guidelines.)
- CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays [Note: Content moved to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management]
- CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome [Note: Content moved to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management]
- CG-GENE-09 Genetic Testing for CHARGE Syndrome [Note: Content moved to CG-GENE-13 Genetic Testing for Inherited Diseases]
Revised clinical guidelines effective April 13, 2022
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-GENE-13 Genetic Testing for Inherited Diseases [Note: Moved content of GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease and CG-GENE-09 Genetic Testing for CHARGE Syndrome into this document.]
- CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management [Note: Moved content of CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document.]
- CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Revised clinical guidelines effective April 13, 2022
(The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- CG-GENE-07 BCR-ABL Mutation Analysis
- CG-GENE-16 BRCA Genetic Testing
- CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing [Note: Content for measurable residual disease testing moved from GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling into this document.]
- CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions
- CG-MED-26 Neonatal Levels of Care
- CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
- CG-MED-68 Therapeutic Apheresis
- CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, Speech-Language Pathology Services
- CG-SURG-09 Temporomandibular Disorders
- CG-SURG-88 Mastectomy for Gynecomastia
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
- CG-SURG-97 Cardioverter Defibrillators
- CG-SURG-99 Panniculectomy and Abdominoplasty
- CG-SURG-104 Intraoperative Neurophysiological Monitoring
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- CG-TRANS-02 Kidney Transplantation
Unadopted clinical guidelines effective May 1, 2022
(The criteria in the following guidelines will no longer be applied.)
- CG-MED-63 Treatment of Hyperhidrosis
- CG-MED-76 Magnetic Source Imaging and Magnetoencephalography
- CG-SURG-05 Maze Procedure
- CG-SURG-28 Transcatheter Uterine Artery Embolization
- CG-SURG-59 Vena Cava Filters
- CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-SURG-79 Implantable Infusion Pumps
- CG-SURG-86 Endovascular/ Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
- CG-SURG-94 Keratoprosthesis
- CG-SURG-104 Intraoperative Neurophysiological Monitoring
- CG-SURG-105 Corneal Collagen Cross-Linking
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
Revised clinical guideline effective August 1, 2022
(The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management [Note: Moved content of CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document effective April 13, 2022.]*
In the April 2022 edition of Provider News, we published incorrect information in the heading of the First Prenatal Visit section of the article. We have corrected the information, and the updated article is included below. We apologize for any inconvenience.
The Federal Employee Program (FEP) is introducing a new Quality Reimbursement Program for PPO providers. Coding for CPT II Category Codes for A1c results, blood pressure readings and the first prenatal visit will now be reimbursed at $10 per code.
CPT II codes are supplemental tracking codes that are used to measure quality performance. The use of these tracking codes decreases the need for record submissions and chart reviews, minimizing administrative burden on physicians and other healthcare professionals.
How to use CPT II codes
Use these CPT II codes when submitting a claim. In field 24F on the CMS-1500 claim form, enter the CPT II code along with the amount of $10. In order to receive reimbursement, the exact dollar amount ($10) and the date of service must be entered on the claim along with the appropriate code for the service performed:
Blood Pressure – Receive $10 for the systolic and the diastolic readings:
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3074F
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Most recent systolic blood pressure less than 130 mm Hg
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3075F
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Most recent systolic blood pressure 130-139 mm Hg
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3077F
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Most recent systolic blood pressure greater than or equal to 140 mm Hg
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3078F
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Most recent diastolic blood pressure less than 80 mm Hg
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3079F
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Most recent diastolic blood pressure 80-89 mm Hg
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3080F
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Most recent diastolic blood pressure greater than or equal to 90 mm Hg
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Hemoglobin A1c:
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3044F
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Most recent hemoglobin A1c (HbA1c) level less than 7.0%
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3046F
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Most recent hemoglobin A1c (HbA1c) level greater than 9.0%
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3051F
3052F
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Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0%
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%
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First Prenatal Visit – The first prenatal visit date of service must be on the claim (Field 24A CMS-1500) with the appropriate code:
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0500F
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Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit, and in a separate field, the date of the last menstrual period [LMP]) (Prenatal)
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0501F
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Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period [LMP] (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit) (Prenatal)
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For additional information about the Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.
This incentive program is for preferred providers who see FEP members. The program can be altered or rescinded at any time.
Preferred providers can receive incentives for using specific CPT II codes when filing claims.
CPT II codes are supplemental tracking codes that are used to measure quality performance.
Use these tracking codes to decrease the need for record submissions and chart reviews -
minimizing administrative burden on you and your healthcare teams.
FEP preferred providers can receive incentives for using specific CPT II codes, including blood pressure readings. Join us for a CPT II code webinar to learn more about filing CPT II codes to receive incentives.
Join us for a live webinar - Everything you need to know about using CPT II Codes
Tuesday, May 10, 2022
12 noon to 1 p.m.
Register here
For additional information about the Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.
This incentive program is for preferred providers who see FEP members. The program can be altered or rescinded at any time.
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 August 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.
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Clinical Criteria
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0062
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Yusimry (adalimumab-aqvh)
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J3590
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ING-CC-0072
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Vabysmo (faricimab-svoa)
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J3490, J3590
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ING-CC-0210
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Enjaymo (sutimlimab-jome)
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C9399, J3490, J3590, J9999
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ING-CC-0211*
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Kimmtrak (tebentafusp-tebn)
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C9399, J3490, J3590, J9999
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ING-CC-0212
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Tezspire (tezepelumab-ekko)
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C9399, J3590
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ING-CC-0213
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Voxzogo (vosoritide)
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C9399, J3490
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Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after August 1, 2022, 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.
Access our clinical criteria to view the complete information for these step therapy updates.
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Clinical Criteria
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Status
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0072
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Non-Preferred
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Vabysmo (faricimab-svoa)
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J3490, J3590
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Quantity limit updates
Effective for dates of service on and after August 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our clinical criteria to view the complete information for these quantity limit updates.
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Clinical Criteria
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0062
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Hulio (adalimumab-fkjp)
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J3590
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ING-CC-0062
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Ixifi (infliximab-qbtx)
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Q5109
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ING-CC-0062
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Yusimry (adalimumab-aqvh)
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J3590
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ING-CC-0072
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Vabysmo (faricimab-svoa)
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J3490, J3590
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ING-CC-0210
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Enjaymo (sutimlimab-jome)
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C9399, J3490, J3590, J9999
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ING-CC-0212
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Tezspire (tezepelumab-ekko)
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C9399, J3590
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ING-CC-0213
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Voxzogo (vosoritide)
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C9399, J3490
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The following clinical criteria documents were endorsed at the February 25, 2022, clinical criteria meeting. Visit our website to access the clinical criteria information.
Revised clinical criteria effective January 1, 2022
The following clinical criteria was updated with new procedure and/or diagnosis codes.
ING-CC-0202 Saphnelo (anifrolumab-fnia)
Revised clinical criteria effective March 1, 2022
The following clinical criteria was updated with new procedure and/or diagnosis codes.
ING-CC-0018 Agents for Pompe Disease
New clinical criteria effective March 16, 2022
The following clinical criteria are new.
- ING-CC-0210 Enjaymo (sutimlimab-jome)
- ING-CC-0211 Kimmtrak (tebentafusp-tebn)
- ING-CC-0212 Tezspire (tezepelumab-ekko)
- ING-CC-0213 Voxzogo (vosoritide)
Revised clinical criteria effective March 28, 2022
The following clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0042 Monoclonal Antibodies to Interleukin-17
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0078 Orencia (abatacept)
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0108 Halaven (eribulin)
- ING-CC-0110 Perjeta (pertuzumab)
- ING-CC-0115 Kadcyla (ado-trastuzumab)
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0120 Kyprolis (carfilzomib)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0126 Blincyto (blinatumomab)
- ING-CC-0129 Bavencio (avelumab)
- ING-CC-0157 Padcev (enfortumab vedotin)
Revised clinical criteria effective March 28, 2022
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
- ING-CC-0075 Rituximab agents for Non-Oncologic Indications
- ING-CC-0085 Actimmune (interferon gamma-1b)
- ING-CC-0088 Elzonris (tagraxofusp-erzs)
- ING-CC-0089 Mozobil (plerixafor)
- ING-CC-0091 Lartruvo (olaratumab)
- ING-CC-0094 Pemetrexed Agents (Alimta, Pemfexy)
- ING-CC-0096 Asparagine Specific Enzymes
- ING-CC-0103 Faslodex (fulvestrant)
- ING-CC-0109 Zaltrap (ziv-aflibercept)
- ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
- ING-CC-0113 Sylvant (siltuximab)
- ING-CC-0117 Empliciti (elotuzumab)
- ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Zevalin)
- ING-CC-0121 Gazyva (obinutuzumab)
- ING-CC-0122 Arzerra (ofatumumab)
- ING-CC-0123 Cyramza (ramucirumab)
- ING-CC-0130 Imfinzi (durvalumab)
- ING-CC-0131 Besponsa (inotuzumab ozogamicin)
- ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
- ING-CC-0135 Melanoma Vaccines
- ING-CC-0140 Zulresso (brexanolone)
- ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
- ING-CC-0164 Jelmyto (mitomycin gel)
- ING-CC-0167 Rituximab Agents for Oncologic Indications
- ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)
- ING-CC-0182 Iron Agents
- ING-CC-0205 Fyarro (sirolimus albumin bound)
Revised clinical criteria effective April 1, 2022
The following clinical criteria were updated with new procedure and/or diagnosis codes.
- ING-CC-0018 Agents for Pompe Disease
- ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
- ING-CC-0202 Saphnelo (anifrolumab-fnia)
- ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
- ING-CC-0204 Tivdak (tisotumab vedotin-tftv)
- ING-CC-0205 Fyarro (sirolimus albumin bound)
Revised clinical criteria effective May 10, 2022
The following clinical criteria was updated with new procedure and/or diagnosis codes.
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
Revised clinical criteria effective August 1, 2022
The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary
- ING-CC-0033 Xolair (omalizumab)
- ING-CC-0043 Monoclonal Antibodies to Interleukin-5
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
- ING-CC-0078 Orencia (abatacept)
- ING-CC-0086 Spravato (esketamine) Nasal Spray
- ING-CC-0090 Ixempra (ixabepilone)
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0166 Trastuzumab Agents
- ING-CC-0186 Margenza (margetuximab-cmkb)
- ING-CC-0209 Leqvio (inclisiran)
The following clinical criteria documents were endorsed at the March 24, 2022, Clinical Criteria meeting. Visit our website to access the clinical criteria information.
New clinical criteria effective April 4, 2022
The following clinical criteria is new.
- ING-CC-0214 Carvykti (Ciltacabtagene autoleucel)
Revised clinical criteria effective April 4, 2022
The following clinical criteria was revised to expand medical necessity indications or criteria.
- ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
Revised clinical criteria effective April 25, 2022
The following clinical criteria was revised to expand medical necessity indications or criteria.
- ING-CC-0125 Opdivo (nivolumab)
Revised clinical criteria effective April 25, 2022
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0037 Kanuma (sebelipase alfa)
- ING-CC-0070 Jetrea (ocriplasmin)
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0159 Scenesse (afamelanotide)
- ING-CC-0166 Trastuzumab Agents
- ING-CC-0167 Rituximab Agents for Oncologic Indications
- ING-CC-0182 Iron Agents
Revised clinical criteria effective August 1, 2022
The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary
- ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
- ING-CC-00208 Adbry (tralokinumab)
Effective March 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.
Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.
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Clinical UM Guidelines
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Preferred drugs
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Nonpreferred drugs
|
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ING-CC-0062
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Inflectra, Remicade, Infliximab (unbranded)
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Avsola, Renflexis
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The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS® measures for measurement year 2022. Below is a summary of the key changes.
Diabetes measures
NCQA has separated the Comprehensive Diabetes indicators into stand-alone measures:
- Hemoglobin A1c Control for Patients with Diabetes (HBD) (HbA1c Control < 8 and Poor Control HbA1c)
- Eye Exam Performed for Patients with Diabetes (EED)
- Blood Pressure for Patients with Diabetes (BPD)
- Kidney Health Evaluation for Patients with Diabetes (KED)
The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move towards more outcome measures.
Race/ethnicity stratification
To address healthcare disparities, the first step is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:
- Colorectal Cancer Screening (COL)
- Controlling High Blood Pressure (CBP)
- Hemoglobin A1c Control for Patients with Diabetes (HBD)
- Prenatal and Post-Partum Care (PPC)
- Child and Adolescent Well Care Visits (WCV)
NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to advancing health equity in data and quality measurement.
New measures
Antibiotic Utilization for Respiratory Conditions (AXR): The percentage of episodes for members three (3) months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event.
This measure was added given antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse. Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the Antibiotic Utilization measure has been retired.
Deprescribing of Benzodiazepines in Older Adults (DBO): The percentage of Medicare members 65 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose during the measurement year.
Guidelines recommend that benzodiazepines be avoided in older adults, and deprescribing benzodiazepines slowly and safely, rather than stopping use immediately. There is an opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population.
Advanced Care Planning (ACP): The percentage of adults 65 to 80 years of age, with advanced illness, an indication of frailty or who are receiving palliative care, and adults 81 years of age and older, who had advance care planning during the measurement year.
Advance care planning is associated with improved quality of life, this measure will allow an understanding if it is provided to those who are most likely to benefit from it. Given this new measure, the Care for Older Adults measure has been retired.
Measure changes
Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line of business and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.
A complete summary of 2022 HEDIS changes and more information, can be found online.
Anthem has partnered with Everlywell* to provide at-home lab tests for a subset of our eligible patients. We mail at-home test kits directly to patients’ homes with instructions on how to complete and return the kits. Clinical laboratory improvement amendments-certified labs process the tests, and an independent physician reviews the results.
We provide PCPs a list of their patients who receive test kit(s) and send individual results to the patient and their doctor. You can help your patients navigate needed testing by encouraging them to complete kits mailed to them. A physician’s recommendation is a significant factor in patient screenings.
A patient may receive up to two at-home test kits:
- Fecal immunochemical test for colorectal cancer screening
- Hemoglobin A1c test to measure average glucose levels over the past two to three months for those with diabetes
How the program works:
- Test kit(s) are automatically mailed to eligible patients, and patient lists are sent to physicians.
- Patients collect samples at home, using instructions provided.
- Patients mail samples to Everlywell in the provided, postage-paid envelope.
- Individual test results are sent to patients and their primary care physician, providing evidence of preventive screening completion.
If you have questions about the at-home testing program, contact your local representative. For additional information about Everlywell, visit everlywell.com.
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