May 2023 Provider News

Contents

AdministrativeCommercialMay 1, 2023

Moving Toward Equity in Asthma Care

AdministrativeCommercialMedicare AdvantageMay 1, 2023

Looking to earn CME credits? Check out the CME Engagement Hub!

AdministrativeCommercialMedicare AdvantageMay 1, 2023

You are invited! Skilled Nursing Facility (SNF) providers: Fall prevention and patient safety

PharmacyCommercialMay 1, 2023

Clinical Criteria updates for specialty pharmacy

PharmacyCommercialMay 1, 2023

Specialty pharmacy updates - May 2023

State & FederalMedicare AdvantageMay 1, 2023

Did your patient have a recent fracture?

State & FederalMedicare AdvantageMay 1, 2023

Genetic testing

State & FederalMedicare AdvantageMay 1, 2023

Keep up with Medicare news

CTBCBS-CRCM-023169-23

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

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

CTBCBS-CRCM-023169-23

AdministrativeCommercialMay 1, 2023

Moving Toward Equity in Asthma Care

Moving Toward Equity in Asthma Care CME Training and Asthma Medication Ratio HEDIS measure update

Moving Toward Equity in Asthma Care
Anthem Blue Cross and Blue Shield is committed to achieving health equity in asthma outcomes with diverse populations. As part of this commitment, we offer an online training, Moving Toward Equity in Asthma Care. This course is accessible from any mobile device or computer and provides one continuing medical education credit at no cost to you. Visit www.mydiversepatients.com.

 Asthma Medication Ratio (AMR) HEDIS® measure
The National Committee for Quality Assurance (NCQA) is also working to identify and reduce disparities in care. As part of this effort, race and ethnicity stratifications were added to the AMR HEDIS metric this year. The AMR metric measures the percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year.

 Did you know: 

  • Hispanics and African Americans with asthma are less likely to take daily controllers and are more likely to visit the ER and be hospitalized for asthma-related conditions than non-Hispanic whites? 1
  • Asian Americans are more likely to die from asthma than non-Hispanic whites?2
  • Appropriate medication management for patients with asthma could reduce the need for rescue medication — as well as the costs associated with ER visits, inpatient admissions, and missed days of work or school?

 Helpful tips:  

  • Ensure at least half of the medications dispensed to treat asthma are controller medications throughout the measurement period. 
  • Talk to the patient about the importance of controller medication compliance, and not to use rescue medications on a regular basis, unless part of asthma action plan.
  • Encourage patients to fill their prescriptions on a regular schedule rather than waiting till they are symptomatic.
  • Create a written asthma action plan in language the patient understands, and schedule follow-up appointments with patients. Ask patients questions to assess asthma control, adherence to the action plan, and identify
  • Utilize evidence-based asthma assessment tools to assess asthma control, adherence to the action plan, and identify triggers.
  • Take the Moving Toward Equity in Asthma Care CME course at no cost for more helpful tips.

Additional resources
Also available is the Asthma & Me training. Do your patients have asthma? Show them the pathophysiology of asthma in their preferred language.

References:

  1. Asthma and Allergy Foundation of America & National Pharmaceutical Council. (2005). Ethnic Disparities in the Burden and Treatment of Asthma. Retrieved from http://www.aafa.org/media/Ethnic-Disparities-Burden-Treatment-Asthma-Report.pdf
  2. U.S. Department of Health & Human Service, Office of Minority Health. (2016, May 9). Asthma and Asian Americans. Retrieved August 8, 2016, from https://www.minorityhealth.hhs.gov
  3. Asthma and Allergy Foundation of America. (2020). Asthma Disparities in America: A Roadmap to Reducing Burden on Racial and Ethnic Minorities. Retrieved from: https://aafa.org/wp-content/uploads/2022/08/asthma-disparities-in-america-burden-on-racial-ethnic-minorities.pdf

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

MULTI-BCBS-CM-019268-23-CPN18979

AdministrativeCommercialMedicare AdvantageMay 1, 2023

Looking to earn CME credits? Check out the CME Engagement Hub!

We’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes.

Engagement Hub objectives:

  • Learn strategies to help you and your care team improve your performance across a range of clinical areas.
  • Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
  • Offer care providers a convenient way to earn CME credits at a time that works best for you.

Register here for our free CME clinical quality webinars!                   

Note: Sessions in this series are approved for one American Academy of Family Physicians credit each.

MULTI-BCBS-CRCM-023027-23-CPN22728

AdministrativeCommercialMedicare AdvantageMay 1, 2023

You are invited! Skilled Nursing Facility (SNF) providers: Fall prevention and patient safety

Join this CME webinar to learn best practices to preventing falls of your older patients Wednesday June 7, 2023.

Skilled Nursing Facility (SNF) providers: Fall prevention and patient safety

MULTI-BCBS-CRCM-023141-23-CPN22841

AdministrativeCommercialMay 1, 2023

Consolidated Appropriations Act: Review your online provider directory information regularly

Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/provider, then under Provider Overview, select Find Care.

Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:

  • Add/change an address location
  • Name change
  • Provider leaving a group or a single location
  • Phone/fax number changes
  • Closing a practice location

Once you submit the form, we will send you an email acknowledging receipt of your request.

The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current.

MULTI-BCBS-CM-022695-23-CPN22692

AdministrativeCommercialMay 1, 2023

Submit corrected claims electronically for the Federal Employee Program®

Providers can submit corrected claims for Federal Employee Program, (FEP), members using Availity Essentials* or through Electronic Data Interchange (EDI). The FEP member ID number start with the letter R, followed by eight numerical digits.

The corrected claims process begins when a claim has already been adjudicated. Multiple types of errors that occur can typically be corrected quickly with the options below. As a reminder, the corrected claim must be received within the timely filing.

Availity Essentials corrected claim submission

You can recreate a claim and submit it as a replacement or cancellation (void) of the original claim if Anthem has already accepted the original claim for processing. Follow these steps:

  • In the Availity Essentials menu, select Claims & Payments, and then select Professional Claim or Facility Claim, depending on which type of claim you want to correct.
  • Enter the claim information, and set the billing frequency and payer control number as follows:
    • Replacement of Prior Claim or Void/Cancel of Prior Claim.
    • Billing Frequency (or Frequency Type) field, in the Claim Information section (for professional and facility claims) or Ancillary Claim/Treatment Information section (for dental claims). Use 7 for replacement claims and 8 for voided claims.
    • Set the Payer Control Number (ICN / DCN) (or Payer Claim Control Number) field to the claim number assigned to the claim by Anthem. You can obtain this number from the 835 ERA or Remittance Inquiry on Payer Spaces.
  • Submit the claim.

EDI corrected claim submission

Corrected claims submitted electronically must also have the applicable frequency code and payer control number.

Frequency code:

  • For corrected professional (837P) claims, use one of the following frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
    • 7 — Replacement of prior claim\corrected claim
    • 8 — Void/cancel prior claim
  • For corrected institutional (837I) claims, use bill type frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
    • 0XX7 — Replacement of prior claim
    • 0XX8 — Void/cancel prior claim

Payer claim control number:

  • Use the original claim number assigned to the claim by Anthem.

Required EDI segments:

  • CLM05-3: Frequency Code (7,8)
  • REF: Payer Claim Control Number (original claim number)

Please confirm with your practice management software vendor and billing service or clearinghouse for full details and information on submitting corrected claims.

We encourage you and your staff to use the digital methods available to submit corrected claims to save costs in mailing, paper, and your valuable time.

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

MULTI-BCBS-CM-022819-23

Digital SolutionsCommercialMay 1, 2023

Important information for providers registered to use Medical Attachments on Availity.com

Digital Request for Additional Information (Digital RFAI) is coming soon.

When your organization registered to use the Medical Attachments application through Availity Essentials,* you also registered to receive digital notifications through that application. This makes it possible for Anthem Blue Cross and Blue Shield (Anthem) to notify you digitally when we need documents to process your claim.

Beginning June 1, 2023, Anthem will notify you through your Attachments Dashboard when we need medical records, itemized bills, or other documents required to process our Commercial member claims. You will no longer receive a paper letter or remittance advice when we need documents to process most claims.

Enabling more efficient processes

Each morning, you will receive Digital RFAI notifications in your Attachments Dashboard Inbox for claims we are unable to process because we need supporting documentation.

How to prepare to receive digital notifications:

  • Check your Medical Attachments application registration:
    • If you are already registered to use the Medical Attachments application, make sure all your billing NPIs are correctly registered.
    • Ask your Availity administrator to verify your registration.
    • Use the self-service learning module to help your Availity administrator check your registration.
  • Check your staff’s security:
    • All team members needing access to attachment information should have these role assignments:
      • Claims Status
      • Medical Attachments
    • Ask your Availity administrator to confirm all the role assignments are correctly applied to the right team members. They need to have access to the organization ID (customer ID) for which the billing NPIs are registered.
    • Use the self-service learning module to help your Availity administrator check your team members role assignments.

Help, training, and support

In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration:

Date

Start time

May 10, 2023

2 p.m. Eastern time

Availity administrators can use this link to register for live training or to view the live training.

For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient:

Date

Start time

May 11, 2023

2:30 p.m. Eastern time

May 12, 2023

11 a.m. Eastern time

May 15, 2023

11 a.m. Eastern time

Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training or to view the live training.

Through this efficient process, we are receiving needed support documentation 50% faster than through the outdated method of mailing letters and receiving attachments through non-digital methods.1 If you are using the PWK process to submit attachments, you may still receive Digital RFAI notifications in your dashboard, if:

  • You didn’t send us the correct document.
  • We need additional documents.
  • The PWK attachment wasn’t received within seven days.

Resources available

Use the helpful resources for information that can help for a smooth transition to Digital RFAI notifications:

For additional resources, call Availity Client Services at 800-282-4548.

1 Source: Internal Digital RFAI provider satisfaction survey

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

CTBCBS-CM-024473-23-CPN22936

Digital SolutionsCommercialMedicare AdvantageMay 1, 2023

Enhanced Provider News website and email communications launching May 1, 2023

Effective May 1, 2023, we will enhance the Provider News website and email communications as part of our commitment to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year.

Stay tuned for more updates.

View the Quick Reference Guide for more information.

CTBCBS-CRCM-016117-22-CPN15788

Medical Policy & Clinical GuidelinesCommercialMay 1, 2023

Transition to Carelon Medical Benefits Management, Inc.* MRI Breast Clinical Appropriateness Guidelines

Effective August 1, 2023, Anthem Blue Cross and Blue Shield will transition the clinical criteria for medical necessity review of MRI Breast to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines:

  • Oncologic Imaging
  • Chest Imaging

As part of this transition of clinical criteria, the following procedures will be subject to prior authorization at Carelon Medical Benefits Management:

CPT® code

Description

77046

Magnetic resonance imaging, breast, without contrast material; unilateral

77047

Magnetic resonance imaging, breast, without contrast material; bilateral

77048

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; unilateral

77049

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; bilateral



HCPCS

 Description

C8903

Magnetic resonance imaging with contrast, breast; unilateral

C8905

Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral

C8906

Magnetic resonance imaging with contrast, breast; bilateral

C8908

Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

  • Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MULTI-BCBS-CM-021989-23-CPN21926

Medical Policy & Clinical GuidelinesCommercialMay 1, 2023

Medical Policy and Clinical Guideline updates are available on our provider website

The following new and revised Medical Policies and Clinical Guidelines were endorsed at the February 16, 2023, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Medical Policies and Clinical Guidelines for Anthem Blue Cross and Blue Shield, are available at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select your state. Then, select View Medical Policies & Clinical UM Guidelines.

To view Medical Policies and Clinical 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]), visit www.fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policy effective August 1, 2023

The following policy is new:

  • MED.00145 Digital Therapy Devices for Treatment of Amblyopia

Revised Medical Policies effective August 1, 2023

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

  • MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
  • SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

Clinical Guideline updates

Revised Clinical Guideline effective August 1, 2023

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-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

MULTI-BCBS-CM-022637-23

Reimbursement PoliciesCommercialMay 1, 2023

Reimbursement policy update: Multiple and Bilateral Surgery Processing - Professional

Beginning with dates of service on or after August 1, 2023, Anthem Blue Cross and Blue Shield’s Multiple and Bilateral Surgery Processing Professional reimbursement policy will be updated to include two new CPT® codes for the Esophagogastroduodenoscopy (EGD) code family.

This policy allows reimbursement for multiple and bilateral procedures. Reimbursement is based on Centers of Medicare & Medicaid (CMS) standard multiple and bilateral procedure rules for multiple arthroscopic and endoscopic surgical procedures.

The Related Coding section has been updated to include the following new CPT codes released by CMS for the Esophagogastroduodenoscopy (EGD) code family:

  • 43290 — Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon:
    • Added CPT code 43290 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent
  • 43291 — Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s):
    • Added CPT code 43291 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent

For specific policy details, visit the reimbursement policy page at anthem.com.

MULTI-BCBS-CM-022967-23-CPN22812

Reimbursement PoliciesCommercialMay 1, 2023

Reimbursement policy update: Robotic Assisted Surgery – Professional

Beginning with dates of service on or after August 1, 2023, Anthem Blue Cross and Blue Shield’s Robotic Assisted Surgery – Professional reimbursement policy will expand to include CPT® codes for computer-assisted surgical systems.

This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed.

The Related Coding section of the policy has been updated to include the following computer assisted surgical musculoskeletal navigation procedures:

  • 0054T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
  • 0055T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
  • 20985: Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)

The policy has been renamed to Technology Assisted Surgical ProceduresProfessional and Facility, which defines both robotic assisted and computer assisted techniques.

For specific policy details, visit the reimbursement policy page at Anthem.com.

MULTI-BCBS-CM-022961-23-CPN22785

Reimbursement PoliciesCommercialMay 1, 2023

New Reimbursement policy: Bundled Supplies and Services - Facility

Beginning with dates of service on or after August 1, 2023, Anthem Blue Cross and Blue Shield will implement a new facility reimbursement policy titled Bundled Supplies and Services – Facility. This policy identifies certain services and/or supplies ineligible for separate reimbursement when reported by a facility. These identified services and/or supplies are an integral component to the overall procedure.

The Related Coding section of the policy lists and describes the Current Procedural Terminology (CPT®) and Healthcare Common Procedural Coding System (HCPCS Level II) codes that are considered always bundled and not eligible for reimbursement when they are reported as a stand-alone service, or with another service. No modifiers will override the denial for the always bundled services and/or supplies.

For specific policy details, visit the reimbursement policy page at anthem.com.

MULTI-BCBS-CM-022955-23-CPN22784

Reimbursement PoliciesCommercialMay 1, 2023

Reimbursement changes to COVID-19 vaccine administration and lab services codes

During the federal Public Health Emergency (PHE) for COVID-19, new COVID-19 laboratory services and vaccine administration codes were implemented and reimbursed at rates to meet the needs of providers during the PHE. As you are aware, the federal PHE for COVID-19 expires May 11, 2023. As a result, Anthem Blue Cross and Blue Shield (Anthem) is providing notice of changes to the reimbursement of both COVID laboratory services and COVID vaccine administration. These changes will not be implemented until August 1, 2023, to help with the transition.

Effective August 1, 2023, reimbursement will be revised to Anthem's standard reimbursement methodology to align with other laboratory services and vaccine administration (for example, flu) rates for the following codes outlined below. The revised standard fee schedule for these codes will be available after August 1, 2023, either on Availity.com* or by reaching out to your Provider Relationship Management representative.

If you have any questions regarding this notice, please contact your Provider Relationship Management representative or use Availity Live Chat, which is available during normal business hours. Go to the Availity Essentials platform and select Anthem from the payer spaces drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

Lab Service Codes

U0001

86328

87426

87811

0224U

U0002

86408

87428

G2023

0225U

U0003

86409

87635

G2024

0226U

U0004

86413

87636

0202U

0240U

U0005

86769

87637

0223U

0241U

Vaccine Administration Codes

CPT® or HCPCS code

CPT or HCPCS short descriptor

Labeler name

Vaccine/procedure name

0001A

ADM SARSCOV2 30MCG/0.3ML 1ST

Pfizer

Pfizer-BioNTech COVID-19 vaccine administration — first dose

0002A

ADM SARSCOV2 30MCG/0.3ML 2ND

Pfizer

Pfizer-BioNTech COVID-19 vaccine administration — second dose

0003A

ADM SARSCOV2 30MCG/0.3ML 3RD

Pfizer

Pfizer-BioNTech COVID-19 vaccine administration — third dose

0004A

ADM SARSCOV2 30MCG/0.3ML BST

Pfizer

Pfizer-BioNTech COVID-19 vaccine administration — booster

0011A

ADM SARSCOV2 100MCG/0.5ML1ST

Moderna

Moderna COVID-19 vaccine administration — first dose

0012A

ADM SARSCOV2 100MCG/0.5ML2ND

Moderna

Moderna COVID-19 vaccine administration — second dose

0013A

ADM SARSCOV2 100MCG/0.5ML3RD

Moderna

Moderna COVID-19 vaccine administration — third dose

0021A

ADM SARSCOV2 5X10^10VP/.5ML 1

AstraZeneca

AstraZeneca COVID-19 vaccine administration — first dose

0022A

ADM SARSCOV2 5X10^10VP/.5ML 2

AstraZeneca

AstraZeneca COVID-19 vaccine administration — second dose

0031A

ADM SARSCOV2 VAC AD26 .5ML

Janssen

Janssen COVID-19 vaccine administration — first dose

0034A

ADM SARSCOV2 VAC AD26 .5ML B

Janssen

Janssen COVID-19 vaccine administration — Booster

0041A

ADM SARSCOV2 5MCG/0.5ML 1ST

Novavax

Novavax COVID-19 vaccine administration — first dose

0042A

ADM SARSCOV2 5MCG/0.5ML 2ND

Novavax

Novavax COVID-19 vaccine administration — second dose

0044A

ADM SARSCOV2 5MCG/0.5ML BST

Novavax

Novavax COVID-19 vaccine, adjuvanted administration — booster

0051A

ADM SARSCV2 30MCG TRS-SUCR 1

Pfizer

Pfizer-BioNTech COVID-19 vaccine (ready to use) administration — first dose

0052A

ADM SARSCV2 30MCG TRS-SUCR 2

Pfizer

Pfizer-BioNTech COVID-19 vaccine (ready to use) administration — second dose

0053A

ADM SARSCV2 30MCG TRS-SUCR 3

Pfizer

Pfizer-BioNTech COVID-19 vaccine (ready to use) administration — third dose

0054A

ADM SARSCV2 30MCG TRS-SUCR B

Pfizer

Pfizer-BioNTech COVID-19 vaccine (ready to use) administration — booster

0064A

ADM SARSCOV2 50MCG/0.25MLBST

Moderna

Moderna COVID-19 vaccine (low dose) administration — booster

0071A

ADM SARSCV2 10MCG TRS-SUCR 1

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine administration — first dose

0072A

ADM SARSCV2 10MCG TRS-SUCR 2

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine administration — second dose

0073A

ADM SARSCV2 10MCG TRS-SUCR 3

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine (orange cap) administration — third dose

0074A

ADM SARSCV2 10MCG TRS-SUCR B

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine (orange cap) administration — booster

0081A

ADM SARSCOV2 3MCG TRS-SUCR 1

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine (aged 6 months through 4 years) (maroon cap) administration — first dose

0082A

ADM SARSCOV2 3MCG TRS-SUCR 2

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine (aged 6 months through 4 years) (maroon cap) administration — second dose

0083A

ADM SARSCOV2 3MCG TRS-SUCR 3

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine (aged 6 months through 4 years) (maroon cap) administration — third dose

0091A

ADM SARSCOV2 50 MCG/.5 ML1ST

Moderna

Moderna COVID-19 pediatric vaccine (aged 6 years through 11 years) (blue cap with purple border) administration — first dose

0092A

ADM SARSCOV2 50 MCG/.5 ML2ND

Moderna

Moderna COVID-19 pediatric vaccine (aged 6 years through 11 years) (blue cap with purple border) administration — second dose

0093A

ADM SARSCOV2 50 MCG/.5 ML3RD

Moderna

Moderna COVID-19 pediatric vaccine (aged 6 years through 11 years) (blue cap with purple border) administration — third dose

0094A

ADM SARSCOV2 50MCG/0.5 MLBST

Moderna

Moderna COVID-19 vaccine (aged 18 years and older) (blue cap with purple border) 50mcg/0.5ml administration — booster

0111A

ADM SARSCOV2 25MCG/0.25ML1ST

Moderna

Moderna COVID-19 pediatric vaccine (aged 6 months through 5 years) (blue cap with magenta border) administration — first dose

0112A

ADM SARSCOV2 25MCG/0.25ML2ND

Moderna

Moderna COVID-19 pediatric vaccine (aged 6 months through 5 years) (blue cap with magenta border) administration — second dose

0113A

ADM SARSCOV2 25MCG/0.25ML3RD

Moderna

Moderna COVID-19 pediatric vaccine (aged 6 months through 5 years) (blue cap with magenta border) administration — third dose

0124A

ADM SARSCV2 BVL 30MCG/.3ML B

Pfizer

Pfizer-BioNTech COVID-19 vaccine, bivalent (gray cap) administration — booster dose

0134A

ADM SARSCV2 BVL 50MCG/.5ML B

Moderna

Moderna COVID-19 vaccine, bivalent (aged 12 years and older) (dark blue cap with gray border) administration — booster dose [6]

0144A

ADM SARSCV2 BVL 25MCG/.25ML B

Moderna

Moderna COVID-19 vaccine, bivalent (aged 6 years through 11 years) (dark blue cap with gray border) administration — booster dose

0154A

ADM SARSCV2 BVL 10MCG/.2ML B

Pfizer

Pfizer-BioNTech COVID-19 vaccine, bivalent product (aged 5 years through 11 years) (orange cap) administration — booster dose

0164A

ADM SRSCV2 BVL 10MCG/0.2ML B

Moderna

Moderna COVID-19 vaccine, bivalent (aged 6 months through 5 years) (dark pink cap and label with a yellow box) administration — booster dose

0173A

ADM SARSCV2 BVL 3MCG/0.2ML 3

Pfizer

Pfizer-BioNTech COVID-19 pediatric vaccine (aged 6 months through 4 years) (maroon cap) administration — third dose

M0201

COVID-19 vaccine home admin

Home vaccine admin

COVID-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only COVID-19 vaccine administration is performed at the patient's home

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

CTBCBS-CM-022828-23

PharmacyCommercialMay 1, 2023

Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the February 24, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective August 1, 2023

The following Clinical Criteria are new:

  • CC-0230 Adstiladrin (nadofaragene firadenovec-vncg)
  • CC-0233 Rebyota (fecal microbiota, live – jslm)

Revised Clinical Criteria effective August 1, 2023

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:

  • CC-0062 Tumor Necrosis Factor Antagonists
  • CC-0086 Spravato (esketamine) Nasal Spray
  • CC-0096 Asparagine Specific Enzymes
  • CC-0110 Perjeta (pertuzumab)
  • CC-0115 Kadcyla (ado-trastuzumab)
  • CC-0116 Bendamustine agents
  • CC-0119 Yervoy (ipilimumab)
  • CC-0120 Kyprolis (carfilzomib)
  • CC-0128 Tecentriq (atezolizumab)
  • CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)

MULTI-BCBS-CM-022636-23

PharmacyCommercialMay 1, 2023

Specialty pharmacy updates - May 2023

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* 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.

Including the National Drug Code (NDC) code on your claim may 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, 2023, 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 site of prior authorization updates.

Clinical Criteria

Drug

HCPCS or CPT® code(s)

CC-0230

Adstiladrin (nadofaragene firadenovec-vncg)

J9999

CC-0062

Idacio (adalimumab-aacf)

J3490, J3590

CC-0231

Lamzede (velmanase alfa-tycv)

C9399, J3490

CC-0232*

Lunsumio (mosunetuzumab-axgb)

C9399, J3490, J3590, J9999

CC-0233

Rebyota (fecal microbiota, live – jslm)

C9399, J3490, J3590

CC-0234

Syfovre (pegcetacoplan)

C9399, J3490

CC-0116*

Vivimusta (bendamustine)

J9999

* Oncology use is managed by Carelon Medical Benefits Management, Inc.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Site of care updates

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our site of care review process.

Access our Clinical Criteria to view the complete information for these site of care updates.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0217

Amvuttra (vutrisiran)

J0225

CC-0194

Cabenuva (cabotegravir extended-release; rilpivirine extended-release)

J0741

CC-0003

Cutaquig (immune globulin)

J1551

CC-0210

Enjaymo (sutimlimab-jome)

J1302

CC-0018

Nexviazyme (avalglucosidase alfa-ngpt)

J0219

CC-0019

Reclast (zoledronic acid)

J3489

CC-0075

Riabni (rituximab-arrx)

Q5123

CC-0075

Ruxience (rituximab-pvvr)

Q5119

CC-0202

Saphnelo (anifrolumab-fnia)

J0491

CC-0212

Tezspire (tezepelumab-ekko)

J2356

CC-0075

Truxima (rituximab-abbs)

Q5115

CC-0207

Vyvgart (efgartigimod alfa-fcab)

J9332

CC-0220

Xenpozyme (olipudase alfa)

J0218

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be removed from our site of care review process.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0004

Acthar (corticotropin)

J0800

CC-0034

Berinert (C1 Esterase Inhibitor, Human)

J0597

CC-0034

Firazyr (icatibant)

J1744

CC-0154

Givlaari (givosiran)

J0223

CC-0034

Kalbitor (ecallantide)

J1290

CC-0013

Mepsevii (vestronidase alfa)

J3397

CC-0073

Prolastin-C (alpha-1 proteinase inhibitor)

J0256

CC-0156

Reblozyl (luspatercept)

J0896

CC-0034

Ruconest (C1 Esterase Inhibitor, Recombinant)

J0596

Quantity limit updates

Effective for dates of service on and after August 1, 2023, 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.

Clinical Criteria

Drug

HCPCS or CPT code(s)

CC-0230

Adstiladrin (nadofaragene firadenovec-vncg)

J9999

CC-0062

Idacio (adalimumab-aacf)

J3490, J3590

CC-0231

Lamzede (velmanase alfa-tycv)

C9399, J3490

CC-0233

Rebyota (fecal microbiota, live – jslm)

C9399, J3490, J3590

CC-0234

Syfovre (pegcetacoplan)

C9399, J3490

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MULTI-BCBS-CM-022993-23-CPN22815

State & FederalMedicare AdvantageMay 1, 2023

Did your patient have a recent fracture?

Who is affected
For women ages 67 to 85 who sustained a recent fracture, it is important to obtain a bone density scan to assess for osteoporosis.

How can we collaborate?
We can help your patients complete this scan in the comfort of their home through Quest HealthConnect™.*

In home resources
We are working with Quest HealthConnect, a Quest Diagnostics service, to provide this service at no added cost to you. Quest HealthConnect will call your patient to arrange a visit. Patients may also call them directly at 888-306-0615 between 8:30 a.m. to 4 p.m. Eastern Time. The result(s) of the screening test(s) will be sent to both the patient and your office after the visit.

* Quest Diagnostics is an independent company providing preventive care technology and health risk assessments services on behalf of the health plan.

MULTI-BCBS-CR-017880-23-CPN17332

State & FederalMedicare AdvantageMay 1, 2023

Genetic testing

For professional claims submitted on a CMS-1500 form processed on or after June 1, 2023, Anthem Blue Cross and Blue Shield will enhance our editing systems to automate edits and simplify remittance messaging. These edit enhancements are supported by correct coding guidelines as documented in industry sources such as Correct Procedural Terminology (CPT®) guidelines and Centers for Medicare & Medicaid Services (CMS). Additionally, these edit enhancements will promote faster claim processing and reduce follow-up audits and/or record requests for claims that are not consistent with correct coding guidelines. As a result of these edit enhancements, there will be greater attention on identifying inappropriate billing of genetic testing services.

Below are examples of claim edits focused on identifying inappropriate billing of genetic testing services that will be automated:

  • Multianalyte Assays with Algorithmic Analyses (MAAA) — CPT 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
  • Panel testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists.
    Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual.

If you have questions on this program, contact your Provider Relationship Account Manager.

MULTI-BCBS-CR-019035-23-CPN18337

State & FederalMedicare AdvantageMay 1, 2023

Update: Authorizations for DMEPOS services for Medicare Advantage Individual, Group Retiree Solutions, and Dual-Eligible plan members

The fax number on the previous communication was incorrect and has been corrected here. The correct fax number is 833-678-0223.

For services beginning on July 1, 2023, prior authorization requests for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services will be reviewed by Carelon Post Acute Solutions, LLC.* The goal of this program is to ensure members receive the right product for the right duration of time in the home. This change will be applicable to the following markets: Colorado, Connecticut, Georgia, Indiana, Kentucky, Missouri, New Hampshire, Nevada, Ohio, Virginia, and Wisconsin.

How to submit or check a prior authorization request
For DMEPOS services, Carelon Post Acute Solutions will begin receiving requests on Tuesday, June 20, 2023, for dates of service July 1, 2023, and after.  

Providers are encouraged to request authorization using the website. Go here to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions at 833-678-0223.

Please note: Carelon Post Acute Solutions will not review authorization requests for products/services that do not fall under Medicare-covered products/services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit the website or email.

If you have additional questions, please call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622.

* Carelon Post Acute Solutions, LLC is an independent company providing services on behalf of the health plan.

MULTI-BCBS-CR-024043-23-CPN24014