 Provider News ConnecticutOctober 2022 Provider Newsletter - ConnecticutThis communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
Care providers are a trusted resource for members when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.
Some care providers may have seen a message on their provider Explanation of Benefits (EOB) stating that Anthem does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOB message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.
To aid in processing claims for the monkeypox and smallpox vaccine products, care providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:
- Product code (90611 or 90622)
- Applicable ICD-10-CM diagnosis code
- Administration code
More detail on codes and cost-sharing
Providers are encouraged to use:
- Product code 90611 for smallpox and monkeypox vaccine.
- Product code 90622 for vaccinia (smallpox) virus vaccine.
- Code 87593 for laboratory testing.
When billing the monkeypox and smallpox vaccine products, care providers should submit those codes with a $0.01 charge.
Cost-sharing for the vaccine is waived.
If you have any questions, contact the Provider Service number on the back of the member’s ID card. You can read more information on monkeypox here.
We are asking you to review your online provider directory information on a regular basis to ensure it is correct. Access your information by visiting www.anthem.com, select For Providers, then choose Go To Providers Overview, select Find Care.
Submit updates and corrections to your directory information using 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 form, we will send you an email acknowledging receipt of your request.
The Consolidated Appropriations Act (CAA) contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. By reviewing your information regularly, you can help us ensure your online provider directory information is current.
The precertification list will be updated effective January 1, 2023. See the attached PDF for the updates.
To obtain precertification, providers can access Availity* at https://www.availity.com or call our Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.
Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.
We understand that submitting authorizations by phone or fax is time consuming and inefficient. We have a digital application, Interactive Care Reviewer (ICR), that makes it easy to submit, review, and check authorization status all in one place, electronically.
We’d like to invite you to a webcast that covers how to:
- Access ICR.
- Create an authorization request.
- Inquire on a previously submitted authorization.
- Update a case.
- Copy a case.
- View letters associated with a case.
- Request and check the status of an authorization appeal.
Join us for an ICR learning webcast:
- Wednesday, October 12, 2022, at 11 a.m. Eastern time
- Register here
Visit the ICR Target page to register and to access self-service learning by viewing recorded learning sessions. Download ICR user guides and other job aides from the ICR Target page too. You can also register from the Provider Learning Hub by clicking on the ICR live webinar learning icon.
Now open for learning!
Understanding how to use the many time saving applications on Availity Essentials* is important to working together digitally. Anthem Blue Cross and Blue Shield has developed a learning place just for that purpose — the Provider Learning Hub.
Using the Provider Learning Hub available from https://www.anthem.com/provider is the easiest and quickest way to access courses and learning guides about claim submission, attachments and status, eligibility and benefits, and more.
These new and improved learning experiences apply to Availity Essentials and electronic data interchange (EDI) transactions:
- Visit the Provider Learning Hub for short, easy-to-follow training videos with supporting resources — no username and password required.
- Handy filtering options make it easy to find what you are looking for.
- The Favorites folder lets you save courses for easy access later.
- Register once and on future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today!
Access the Provider Learning Hub today using this link or from https://www.anthem.com/provider under Important Announcements on the home page.
Beginning with dates of service on or after January 1, 2023, Anthem Blue Cross and Blue Shield will update the Related Coding section of the policy with the following:
- Added CPT code 43497 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.
Effective as of July 27, 2022, Anthem Blue Cross and Blue Shield updated the title of the Three-Dimensional (3D) Radiology Services - Professional policy to Three-Dimensional (3D) Radiology Services – Professional and Facility. This policy will continue to apply only to professional providers.
For specific policy details, visit the reimbursement policy page at the anthem.com provider website.
Beginning with dates of service on or after January 1, 2023, Anthem Blue Cross and Blue Shield will implement a new facility reimbursement policy titled Place of Service – Facility.
The policy outlines professional services that can be rendered in an office, professional building, medical office building, clinic or a space owned by a hospital or an institutional provider, other than the primary structure on the campus of the hospital or institutional provider or rented by a professional from the hospital or an institutional provider.
Evaluation & Management (E/M) services and other professional services must be billed on a CMS-1500 claim form and are not reimbursable if they are billed on a UB-04 claim form (excluding E/M services rendered in an emergency room and billed with ER Revenue codes). In addition, professional services billed under revenue codes 960-983 and preventive counseling CPT codes 99401-99404, 99411 and 99412 when billed in an outpatient setting of a facility are not reimbursable when submitted on a UB-04.
For specific policy details, visit the reimbursement policy page on the provider website.
Effective July 8, 2022, Federal Employee Program (FEP) for Anthem Blue Cross and Blue Shield (Anthem) began participating in a real-time provider chat option through Availity* Essentials. The secure portal allows providers to seek real-time answers to questions about prior authorization, precertification requirements, status check, and more.
Currently, only Missouri and Georgia providers can access the chat capability for Federal members. Chat is available from 8 a.m. to 7 p.m. ET through the secure provider website found at www.availity.com. Select Payer Spaces, Anthem, and access the chat through Chat with Payer.
Chat is one example of how FEP is using digital technology to improve the health care experience with the goal of saving valuable time.
With the success of the real-time chat option for Federal members, Anthem is implementing additional states ranging in dates from October 2022 through the first quarter of 2023.
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of nononcology 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.
Inclusion of the National Drug Code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code.
Step therapy updates
Effective for dates of service on and after January 1, 2023, 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.
Please note that infliximab agents are subject to step therapy today, and this is to notify of the changes in the preferred and nonpreferred products. Inflectra will become non-preferred and Avsola will become preferred as of January 1, 2023.
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
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ING-CC-0062
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Preferred
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Remicade
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J1745
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ING-CC-0062
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Preferred
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Infliximab Unbranded
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J1745
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ING-CC-0062
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Preferred
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Avsola
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Q5121
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ING-CC-0062
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Nonpreferred
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Inflectra
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Q5103
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ING-CC-0062
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Nonpreferred
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Renflexis
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Q5104
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Visit the Drug Lists page on www.anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes
- Drug lists and changes
- Prior authorization criteria
- Procedures for generic substitution
- Therapeutic interchange
- Step therapy or other management methods subject to prescribing decisions
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The Commercial and Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
The following Clinical Criteria documents were endorsed at the August 19, 2022, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.
Revised Clinical Criteria effective August 30, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
Revised Clinical Criteria effective August 30, 2022
The following Clinical Criteria was reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0007 Synagis (palivizumab)
Revised Clinical Criteria effective September 19, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0100 Istodax (romidepsin)
- ING-CC-0104 Levoleucovorin Agents
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0140 Zulresso (brexanolone)
- ING-CC-0142 Somatuline Depot (lanreotide)
- ING-CC-0180 Monjuvi (tafasitamab-cxix)
- ING-CC-0182 Iron Agents
- ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
- ING-CC-0188 Imcivree (setmelanotide)
- ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
- ING-CC-0216 Opdualag (nivolumab and relatlimab-rmbw)
Revised Clinical Criteria effective September 19, 2022
The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0001 Erythropoiesis Stimulating Agents
- ING-CC-0004 Repository Corticotropin Injection
- ING-CC-0008 Subcutaneous Hormonal Implants
- ING-CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
- ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
- ING-CC-0020 Tysabri (natalizumab)
- ING-CC-0027 Denosumab Agents
- ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
- ING-CC-0036 Naltrexone Implantable Pellets
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0044 Exondys 51 (eteplirsen)
- ING-CC-0139 Evenity (romosozumab-aqqg)
- ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)
- ING-CC-0152 Vyondys 53 (golodirsen)
- ING-CC-0156 Reblozyl (luspatercept)
- ING-CC-0171 Zepzelca (lurbinectedin)
- ING-CC-0172 Viltepso (viltolarsen)
- ING-CC-0174 Kesimpta (ofatumumab)
- ING-CC-0179 Blenrep (belantamab mafodotin-blmf)
- ING-CC-0189 Amondys 45 (casimersen)
- ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
- ING-CC-0193 Evkeeza (evinacumab)
- ING-CC-0197 Jemperli (dostarlimab-gxly)
- ING-CC-0200 Aduhelm (aducanumab-avwa)
- ING-CC-0202 Saphnelo (anifrolumab-fnia)
- ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
- ING-CC-0208 Adbry (tralokinumab)
- ING-CC-0209 Leqvio (inclisiran)
- ING-CC-0217 Amvuttra (vutrisiran)
Revised Clinical Criteria effective January 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:
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0028 Benlysta (belimumab)
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0034 Hereditary Angioedema Agents
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0058 Octreotide Agents
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0082 Onpattro (patisiran)
- ING-CC-0142 Somatuline Depot (lanreotide)
- ING-CC-0176 Beleodaq (belinostat)
- ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)
New Clinical Criteria effective January 1, 2023
The following Clinical Criteria is new:
- ING-CC-0219 Korsuva (difelikefalin acetate)
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Connecticut.
Our pharmacy benefit management partner, IngenioRx,* will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.
This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.
If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:
- IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
- IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.
These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.
When e-prescribing orders to the mail and specialty pharmacies:
- Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
- If searching by NPI (National Provider Identifier), the NPI will not change.
In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.
Keeping you well informed is essential and remains our top priority. We will continue to provide updates prior to January and throughout 2023.
Effective for dates of service on and after October 1, 2022, updated step criteria for immunoglobulins found in Clinical Criteria document ING-CC-0003 has been implemented. The preferred product list is being expanded. Please refer to the Clinical Criteria page for more information.
(Policy 21-001, effective 01/01/2022)
In the October 2021 edition of the provider newsletter, we announced that a new reimbursement policy titled Sexually Transmitted Infections Testing — Professional would be effective for dates of service on or after January 1, 2022. We have made a decision to retract this reimbursement policy.
If you have any questions, contact your Provider Experience associate or visit the Contact Us page on our provider website (https://www.anthem.com/medicareprovider) for up-to-date contact information.
The attached FAQ communication is designed to provide general guidance for questions related to Medicare telehealth services during the Coronavirus (COVID-19) Public Health Emergency (PHE). The PHE is ongoing and ever evolving; therefore, Anthem Blue Cross and Blue Shield (Anthem) wants to support accurate and up-to-date information around legal and regulatory changes that may impact healthcare.
This FAQ is for informational purposes only and is intended to provide guidance regarding the changing landscape of Medicare telehealth. This guidance is not all-inclusive; it is intended to address frequently asked questions and common Medicare telehealth topics. The content included herein is not intended to be a substitute for the provisions of applicable statutes or regulations or other relevant guidance issued by CMS, as those items are subject to change from time-to-time.
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