 Provider News GeorgiaAugust 2018 BCBSGa Provider NewsletterA key goal of BCBSGa’s provider transparency efforts is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Enhanced Personal Health Care (EPHC) Program quality and/or cost information about the health care providers to which the PCPs refer their Attributed Members (the “Referral Providers”). If a Referral Provider is higher quality and/or lower cost, this component of the program should result in their getting more referrals from PCPs. The converse should be true if Referral Providers are lower quality and/or higher cost. Additionally, employers and groups health plans (or their representatives or vendors) may also be given quality/cost information so that they can better understand how their health care dollars are being spent. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.
Cost Opportunity Report
- The Cost Opportunity Report is available for EPHC providers to access via Provider Care Management Solutions (PCMS).
- The report was created to help users quickly identify meaningful and actionable opportunities to optimize costs and help achieve shared savings targets within the EPHC Program.
- By providing a standard set of potential cost opportunity metrics, the Cost Opportunity Report and be used to help evaluate the relative success of providers within the EPHC Program.
- Metrics are selected based on size of financial opportunity, ability of PCPs to affect changes, mix of impacted service types, mix of utilization and unit price impact.
- Metrics are reviewed on a periodic basis and may be added, changed or removed.
BCBSGa will share data on which it relied in making these quality/cost evaluations upon request, and will discuss it with Referral Providers including any opportunities for improvement. For questions or support, please refer to your local network representative or Care Consultant. BCBSGa has partnered with Availity to become our designated EDI Gateway. The effort is currently underway, and both are committed to providing transparency for our customers.
All EDI submissions currently received today via the BCBSGa EDI Gateway are all now available on the Availity EDI Gateway. There is no impact to the provider’s participation status with BCBSGa and no impact on how claims adjudicate.
If you are connected to Availity you can use your same connection for your EDI submissions.
If you are using another clearinghouse, contact your clearinghouse to validate their transition dates. If your clearinghouse notifies you of changes regarding connectivity, workflow, or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.
Your organization can register with Availity to submit the following transactions:
- 837- Institutional
- 837- Professional
- 837- Dental
- 835- Electronic Remittance Advice
- 276/277- Claim Status – real-time
- 270/271- Eligibility – real-time
Next steps:
- BCBSGa and Availity will continue to communicate and provide assistance with this transition going forward.
- Availity will be working directly with all trading partners.
- We do recommend that you register with Availity for your EDI transmissions for a free fully subsidized option.
How to register with Availity:
- If your organization is not already registered with Availity you can go to availity.com, click REGISTER and then follow the steps to register.
- Look for emails, from Availity, containing your log in credentials.
- If your organization is already registered with Availity, you can log in and click My Providers | Enrollments Center if you need to complete new 835 enrollment or make changes.
We look forward to delivering a smooth transition to the Availity EDI Gateway.
If you have any questions please contact Availity Client Services at 1-800-282-4548 Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time.
As announced in the February 2018 edition of the BCBSGa provider newsletter, we will continue hosting in-person Town Hall style provider orientation meetings throughout 2018. There have been a few updates to the schedule and while the schedule is subject to change, at this time we plan to have the following provider Town Hall meetings:
September 6, 2018 – Savannah
Candler Hospital
The Marsh Auditorium
5353 Reynolds Street
Savannah, GA. 31405
1:00 p.m. – 3:00 p.m.
Refreshments will be provided
Please R.S.V.P. by Friday, August 31st to RSVPBlue@bcbsga.com. Include the name of the facility or practice, and the number of attendees
September 27, 2018 – Macon
The Medical Center of Central Georgia, Navicent Health
Eversole Auditorium
777 Hemlock Street
Macon, GA. 31201
11:30 a.m. – 1:30 p.m.
Lunch will be provided
Please R.S.V.P. by Friday, September 21st to RSVPBlue@bcbsga.com. Include the name of the facility or practice, and the number of attendees
October 11, 2018 – Augusta
Augusta University
Hamilton Wing
1120 15th St
Augusta, GA. 30912
11:30 a.m. – 1:30 p.m.
lunch will be served
Please R.S.V.P. by Tuesday, October 2nd to RSVPBlue@bcbsga.com. Include the name of the facility or practice, and the number of attendees
November 13, 2018 – Atlanta
DeKalb Medical
Theatre
(Use the A Elevators to go to the ground floor, turn left and follow the signs for the Theatre/Auditorium)
2701 North Decatur Road
Decatur GA 30030
10:00 a.m. – 12:00 p.m.
Breakfast will be served
Please R.S.V.P. by Wednesday, November 7th to RSVPBlue@bcbsga.com. Include the name of the facility or practice, and the number of attendees
Availity Webinar Schedule:
In response to provider feedback, and as part of our commitment to support and enable providers, we are pleased to provide Availity overview training. Please plan to attend the upcoming webinar and learn more on the following:
- Eligibility & Benefits
- Claim Inquiry
- Remittances
- Interactive Care Review (ICR)
Webinar is scheduled for October 17th from 1:00 p.m. – 2:00 p.m. By the end of 2018, BCBSGa members will begin receiving a new explanation of benefits (EOB) that is designed to help members better understand their health care benefits and out-of-pocket expenses. The new design will look more like a health care summary. EOBs will continue to include important information about services rendered, the amount paid to the provider, and the member out-of-pocket expense.
The new EOB will also include:
- Ways members can save on health care expenses
- A preventive care checklist, sharing important screenings that were missed
- A summary of the member’s most recent claims
Learn more about our newly designed EOB. BCBSGa’s Care and Cost Finder tool provides many BCBSGa members with the ability to search and compare cost and quality measures for in-network providers using the secure member portal at bcbsga.com. The Care and Cost Finder tool currently offers multiple sorting options, such as sorting providers based on distance or name.
Beginning October 14, 2018, Care and Cost Finder will have a new sorting option called “Personalized Match”. The sorting option is based on algorithms which will use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures. These member and provider features will be combined to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius will be displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius.
Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.
- Providers may review a copy of the new sorting methodology here.
- If you have general questions about the Care and Cost Finder tool or this new sorting option, please contact Provider Customer Service.
- If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-5250.
BCBSGa will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions.
Effective for professional claims (CMS-1500) processed on or after November 18, 2018, BCBSGa will enhance our editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT, HCPCS Level II, and International Classification of Diseases 10 (ICD-10). As a result, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day. This enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.
Below are examples of claim edits that will be automated:
- Accurate reporting of modifiers, including LT, RT, 54, 55, 56, 62,76, 77, 78, 79, 80, 81, 82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.
- Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.
- Assessing whether services considered once in a lifetime have been billed more than once.
- Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together.
As we move to full medical necessity review of all elective inpatient admissions on 09/01/2018, you will need to include the clinical information to complete the medical necessity review when the request is submitted. The Affordable Care Act (ACA) requires many health plans to cover recommended preventive care services without member cost sharing when the services are rendered by an in-network provider and/or facility. Screening colonoscopies (even when polyps are removed) are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT and ICD-10 codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.
The following services are covered with no member cost share:
- The colonoscopy screening procedure.
- Anesthesia charges when anesthesia is billed with the appropriate screening CPT code (even when polyps are removed).
- Other associated facility charges when the colonoscopy is billed with an appropriate screening diagnosis code.
- When polyps are removed during a screening colonoscopy - the removal, examination and analysis of the polyps.
In the instance where a screening colonoscopy starts out as screening but turns into a diagnostic procedure due to polyps being removed, BCBSGa follows CPT guidelines for our Commercial members, not Medicare guidelines. The CPT® 2018 Professional Edition manual shares the following information regarding the billing of anesthesia for any screening colonoscopy, “Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings.” As part of our commitment to provide you with the latest clinical information, we have posted a VBAC shared decision making aid to our provider portal. This is a tool for you to discuss with your patients to aid in making a decision regarding their treatment options. This “ Shared Decision Making Aid” has been reviewed and certified by the Washington Health Care Authority (HCA) and is available under Practice Guidelines on the Health & Wellness page of our bcbsga.com/provider website. In an effort to better service our providers right the first time, we have improved our provider claim escalation process. Our provider service team has been restructured to better handle your inquiry at the time of your call. All inquiries related to claims payment will be directed to BCBSGa self-service tools or provider customer service.
If you have a claim, benefit or eligibility question, contact provider customer service by calling the number on the back of the member’s identification card or utilizing one of the self-service tools, such as secure messaging through Availity, EDI, Interactive Care Reviewer (ICR) or our Interactive Voice Response (IVR). If you’re still not satisfied, you can escalate your inquiry at that time by requesting to speak with a supervisor. Make sure to document the call reference number that will be provided to you at the end of your call or your online inquiry for your records.
As was previously communicated in the December 2017 provider newsletter, BCBSGa has established a contractual relationship with Alliant Health Solutions to assist the organization in validating provider compliance with applicable reimbursement policies and identify instances of incorrect billing for behavioral health services. Alliant has initiated the work and your compliance is required should you receive a request for information. Alliant, is a behavioral health audit and review company, and will examine BCBSGa outpatient behavioral health claims data. Utilizing systematic sampling methodology and a broad range of algorithms, the audits and findings will be customized to support BCBSGa’s expectations as outlined in the BCBSGa Provider Manuals and related policies and procedures. Alliant findings may result in provider audits and record reviews, education and other direct outreach.
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (collectively “BCBSGa”) would like to make you aware of an important change. Effective January 1, 2019 we will be changing our trade name to Anthem Blue Cross and Blue Shield (Anthem), a trusted name that symbolizes quality for millions of consumers across the country. The new name will provide a recognizable brand identity for new, innovative programs, services and tools for existing and new consumers, and assist the market in the simplification of understanding our networks.
While our trade name and logo will change on January 1, 2019, almost everything else will stay the same. The trade name and logo change will be a seamless transition for our providers and hospitals as there will be no change to benefits or provider networks. You will continue to use the same provider IDs, contacts and claims filing processes you’re familiar with. Our members will continue to use the same doctors and hospitals and have access to the same programs and services.
Georgia is still home Our local headquarters will remain in Buckhead, Atlanta under the leadership of Jeff Fusile, our Plan President. Our provider engagement, underwriting, operations and sales teams will still be here, too. Our Anthem Technology Center in downtown Atlanta will support business functions across our entire company, and our parent company’s largest customer service center is located in Columbus, Georgia.
Looking ahead
Starting January 1, 2019, you’ll find us on the web at anthem.com. We’ve given more than 80 years of dedicated service to our Georgia members. That’s not going to change. In 2019, we’ll carry on that same proud legacy ─ except we’ll do it as Anthem Blue Cross and Blue Shield. The Interactive Care Reviewer (ICR)* tool offers a streamlined process to request inpatient and outpatient procedures as well as locate information on previously submitted requests for BCBSGa members via the Availity Portal.
As you know, the ICR tool provides many benefits including fax reduction, authorization determination and a comprehensive view of all your authorization requests. In addition to these benefits, the ICR tool has recently completed some enhancements to improve convenience and efficiency.
Enhancements to the ICR tool include:
- Increase in saved Favorites: The number of favorites that can be saved increased to 25 for all provider types including requesting, servicing, facility DME, and refer to providers.
- Changes to ICR Dashboard tabs: The Authorization Referral Inquiry tab at the top of the dashboard changed to Check Case Status tab. The Search Organization Requests changed to Search Submitted Requests.
- Check Case Status: The ability to view any cases submitted that are associated with the tax IDs on the request. This includes submission by phone, fax, and etc.
- Search Submitted Requests: The ability to search for any ICR case requested by your organization or a request that your organization is associated with. This includes requests with a status of review not required.
- Changes to Check Case Status tab: The Search by Reference Referral Number changed to Search by Reference/Authorization Request Number.
- Search by Reference Authorization Request Number: The ability to search by reference request number or authorization request number and a tax ID associated with the case.
To learn more about the ICR tool attend one of the monthly ICR webinars by registering HERE.
*Note: ICR is not currently available for Federal Employee Program® (FEP), BlueCard®, and some National Account members; requests involving transplant services; or services administered by AIM Specialty Health® or OrthoNet. For these requests, follow the same authorization process that you use today. Are you a BCBSGa provider that needs help transitioning to using Availity’s Gateway solutions? Are you looking for SFTP or other batch upload options? If yes, check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session.During this fast-paced hour, you’ll learn how to:
- Understand Availity’s EDI Gateway and Clearinghouse workflow
- Enroll for and manage 835 ERA delivery with Availity
- Use the Availity Portal to manage file transfers, set up EDI reporting preferences, and more.
- Access and navigate the Availity EDI Guide.
Enroll for one of the following upcoming webinars (and check back again later for additional dates and times):
- Monday, 8/20/2018, 3:00 p.m. to 4:00 p.m. Eastern time
- Thursday, 8/23/2018, 1:00 p.m. to 2:00 p.m. Eastern time
- Tuesday, 9/25/2018, 12:00 noon to 1:00 p.m. Eastern time
- Thursday, 9/27/2018, 3:00 p.m. to 4:00 p.m. Eastern time
To enroll:
- Log in to the Availity Portal.
- Click Help & Training | Get Trained.
- In the Catalog, click Sessions.
- Scroll through Your Calendar to view upcoming live events.
Tip: You can also search the ALC Catalog by a special keyword set up just for you. The keyword is “song.”
For additional training, you can search the Catalog by keyword to access live and on-demand training recommendations curated by Availity Learning especially to help you with this transition. The keyword is “song” for BCBSGa.
Has your office received a request for additional information to process a claim for a BCBSGa member? Those records can now be submitted electronically using the Medical Attachments feature on the Availity Portal.
The Medical Attachments feature makes submitting electronic documentation in support of a claim simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Blue Cross and Blue Shield of Georgia) medical record attachments.
Our solicited Medical Attachments feature supports an unlimited number of document attachments for each submission, and can handle .tiff, .jpg and .pdf attachments. Once your office receives a letter requesting additional documentation, you can send up to 10 attachments through the portal for each claim. The maximum file size is 10MB per attachment and file sizes larger than 10MB can be split into smaller ones.
How to access solicited Medical Attachments for your office
Availity Admin, complete these steps:
From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:
- Select Application>choose Medical Attachments Registration
- Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs Multiples can be added separated by spaces or semi-colons
- Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name
Using Medical Attachments
Availity User, complete these steps:
- Log in to availity.com
- Select Claims and Payments > Medical Attachments >Send Attachment tab
- Complete all required fields on the form
- Attach supporting documentation
- Select Submit
Need Training?
To access additional training for this Availity feature:
- Log in to the Availity Portal at availity.com
- At the top of any Availity portal page, choose Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
- In the catalog, click Sessions.
- Scroll through Your Calendar to view the upcoming live events.
Tuesday, 08/14/2018, 3:00 p.m. to 4:00 p.m. ET
Wednesday, 08/29/2018, 12:00 noon to 1:00 p.m. ET
You can also search the ALC Catalog by a special keyword set up just for you. The keyword is MEDATT.
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 reality is burden of illness, premature death, and disability disproportionately affects certain populations*. MyDiversePatient.com features robust educational resources to help support you in addressing these disparities. You will find:
- CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.
- Real life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
While there’s no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends…one patient at a time.
Accelerate your journey to becoming your patients’ trusted health care partner by visiting MyDiversePatient.com today.
* Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Report. Vol 62(Suppl 3); p3. Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions. Blue Cross and Blue Shield of Georgia offers a new online learning course – What Matters Most: Improving the Patient Experience, to address gaps in and offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide and is acceptable for up to one (1) prescribed credit by the American Academy of Family Physicians.
Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices. Did you know?
- Substantial evidence points to a positive association between the patient experience and health outcomes.
- Patients with chronic conditions, such as Diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.
- Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.
How will this benefit you and your office staff? You’ll learn tips and techniques to:
- Improve communication skills.
- Build patient trust and commitment.
- Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
The course can be accessed at patientexptraining.com using your smartphone, tablet, or computer.
Like you, Blue Cross and Blue Shield of Georgia is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.
Take the course today!
We continually update our provider directories to help ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice – updating address and/or phone number, adding or deleting a physician from your practice, etc. – please notify us by completing the BCBSGa Provider Maintenance Form located on the Provider Forms page of our provider website, bcbsga.com. Thank you for your help and continued efforts to keep our records up to date. As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually, and updated as needed. The current guidelines are available on the Health & Wellness page of our provider website. We have completed the HEDIS data collection for 2018 and want to thank all of our provider offices and their staff who assisted us. Your collaboration in this process allows us to strive for the best HEDIS results possible.
This is the 7th year for our incentive program to acknowledge some of our providers who either responded in a timely manner or went “Above & Beyond” to help make our HEDIS data collection successful. Any practices that responded within 5 business days of our initial request or who went out of their way by taking additional steps to help us with data collection were entered in a drawing to receive a gift. We are pleased to announce that our incentive winners are as follows:
Georgia winners – HEDIS drawing:
- Piedmont NeuroSurgery
- Children’s Wellness Center LLC
- Spectrum Pediatric Group PC
- Greater Athens Physcians, Inc.
- Harron Eyecare
Georgia winner – Above & Beyond:
- Piedmont Physicians Group
Our HEDIS results reflect the care you provide to our members. Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.
An overview of our HEDIS rates will be published in the 4th quarter provider newsletter. In addition more information on HEDIS can be found by visiting the Quality Improvement and Standards page under the Health & Wellness drop down menu on our provider website.
Thanks again to all of our provider offices and their staff for assisting us in collecting HEDIS data. We look forward to working with you next HEDIS season!
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Beginning with dates of service on and after October 29, 2018, the following updates will apply to AIM Advanced Imaging Clinical Appropriateness Guidelines:
CT Chest guideline:
- Expanded list of diagnostic testing abnormalities that may be followed up with CT to include endoscopy, fluoroscopy, and ultrasound in addition to specific chest radiography findings
- Lengthening of timeframe required prior to imaging for chronic cough from 3 to 8 weeks, and more specifics of preliminary workup required prior to imaging
- Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
- Allowance for use of imaging in the staging of malignancy prior to biopsy confirmation
- Allowance for imaging of suspected pulmonary embolism in pregnancy
- New criteria for appropriate imaging of chest wall mass
CT Angiography (CTA) Chest guideline:
- Allowance for imaging of suspected pulmonary embolism in pregnancy
CT Abdomen/CT Pelvis/CT Abdomen & Pelvis guideline:
- Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
MRI Chest guideline:
- Inclusion of imaging of suspected pectoralis muscle tear
- New criteria for appropriate imaging of chest wall mass
MRI Abdomen guideline:
- Addition of hemochromatosis as an indication for imaging in pediatric patients
Ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways:
- Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Additionally, you may access and download a copy of the current guidelines here.
Effective for dates of service on and after November 1, 2018, AIM Specialty Health ® (AIM), a separate company, will apply AIM’s Radiation Oncology Clinical Appropriateness Guidelines to prior authorization requests for the services noted below. These guidelines will replace certain BCBSGa radiation oncology medical policies and clinical guidelines, which are being archived. This update applies to BCBSGa plans with radiation oncology services medically managed by AIM.
- Proton beam radiation therapy
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortallSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Please note, this program does not apply to FEP or National Accounts.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. To better assess measures of quality for our members, BCBSGa will begin requiring documentation of a newborn’s gestational age at the time of delivery for all physician delivery claims.
Beginning with dates of service on and after November 1, 2018, all professional delivery claims (59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620 and 59622) will require an ICD-10 Z3A code indicating the newborn’s gestational age at the time of delivery. If the code is not found on the claim, the claim will be denied with the following reason: “Delivery diagnoses incomplete without report of pregnancy weeks of gestation. You may resubmit the corrected claim with the appropriate ICD-10 code for payment.” Beginning with dates of service on and after November 1, 2018, BCBSGa will expand prior approval requirements to include upper gastrointestinal (GI) endoscopy, also referred to as esophagogastroduodenoscopy (EGD). AIM Specialty Health® (AIM), a separate company, will administer this EGD review on behalf of BCBSGa.
EGD procedures will be reviewed against clinical guideline CG-MED-59, Upper Gastrointestinal Endoscopy, for clinical appropriateness and to help ensure care aligns with established evidence-based medicine. Please note, procedures performed in an inpatient or observation setting, or on an emergent basis will not be reviewed under CG-MED-59.
A complete list of EGD CPT codes requiring prior authorization is available on the AIM Surgical Procedures website.
Submit a request for review
Starting October 17, 2018, ordering providers may submit prior authorization requests for dates of service November 1, 2018 and after to AIM in one of the following ways:
- Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for BCBSGa members at Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements at bcbsga.com/provider. Providers should continue to verify eligibility and benefits for all members prior to rendering services.
For questions, please contact the Provider Service number on the back of the member ID card. BCBSGa’s medical policy, THER-RAD.000002 Proton Beam Radiation Therapy will be archived effective November 1, 2018. This policy will be applied as a part of AIM Clinical Guidelines beginning November 1, 2018. Preapproval changes are listed in the attachment. For additional information, you can access the complete Georgia Standard Preapproval List, Georgia Standard Preapproval CODE List and Georgia Standard Adopted Clinical Guideline List using the following links:
AIM Specialty Health®
AIM Specialty Health, a separate company, is a nationally recognized leader delivering specialty benefits management on behalf of GA for certain health plan members. Determine if preapproval is needed for a GA member by clicking the “Medical Policy, Clinical UM Guidelines, and Preapproval Requirements” link on our provider website or by calling the preapproval phone number printed on the back of the member’s ID card. To submit your request for any of the services below, contact AIM online via AIM’s ProviderPortal sm at aimspecialtyhealth.com/goweb. From the drop-down menu, select GA. You may also call AIM toll-free at 866-714-1103, Monday–Friday, 8:00 a.m. –6:00 p.m. ET. AIM provides benefits management for the programs listed below:
- Imaging Level of Care
- Genetic Testing
- Diagnostic Imaging Management
- Cardiovascular Services
- Radiation Therapy Services
- Outpatient Sleep Testing and Therapy Services
- Specialty Pharmacy Drugs
- Cancer Care Quality Program
- Musculoskeletal (effective date yet to be determined)
- Upper Gastrointestinal Endoscopy (effective 11/1/2018)
For more details on these programs, please visit the AIM Specialty Health® site at aimspecialtyhealth.com/marketing/guidelines/185/index.html. By clicking on the link above, you will be linked to sites created and/or maintained by another, separate entity (“External Site”). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites. The information contained on the External Sites should not be interpreted as medical advice or treatment provided by us. New AIM Musculoskeletal (MSK) Program - Delay in launch for Fully Insured - effective date yet to be determined
The December 2017 edition of the Network Update announced that AIM Specialty Health® (AIM), a separate company, would perform prior authorization reviews of certain surgeries of the spine and joints, as well as interventional pain treatment to determine medical necessity for fully insured BCBSGA members. Please be aware that this program has been delayed. The new implementation date is yet to be determined. The new musculoskeletal program includes review of the level of care/setting, pre-operative days, and expected length of stay for medical necessity using AIM clinical guidelines which have been adopted by BCBSGA. All codes and clinical guidelines included in the musculoskeletal program can be found on the AIM MSK website. Eligibility and benefits Eligibility and benefits can be verified by accessing the BCBSGa/BCBSHP web site bcbsga.com or by calling 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. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. Except in the case of an emergency, failure to obtain preapproval prior to rendering the designated services listed below will result in denial of reimbursement. See attachment to view a list of preapproval changes. The Medical Policy and Technology Assessment Committee adopted the following new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Blue Cross Blue Shield and all the Medical Policies are available at bcbsga.com/provider under “see policies and guidelines”. Please note that our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday through Friday from 8 AM to 7 PM or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to:
Blue Cross Blue Shield of Georgia and Blue Cross Blue Shield Healthcare Plan of Georgia
Attention: Prior Approval, Mail Code GAG009-0002
3350 Peachtree Road NE
Atlanta, GA 30326
NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a Group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.
|
Publish Date
|
Action
|
Policy or Guideline Number
|
Policy or Guideline Title
|
|
11/1/2018
|
New
|
DRUG.00098
|
Lutetium Lu 177 dotatate (Lutathera®)
|
|
11/1/2018
|
New
|
CG-LAB-12
|
Testing for Oral and Esophageal Cancer
|
|
11/1/2018
|
New
|
CG-MED-71
|
Wound Care in the Home Setting
|
|
|
|
|
|
|
6/28/2018
|
Conversion New
|
CG-DME-44
|
Electric Tumor Treatment Field (TTF)
|
|
6/28/2018
|
Conversion Archived
|
DME.00035
|
Electric Tumor Treatment Field (TTF)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-67
|
Cetuximab (Erbitux®)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00036
|
Cetuximab (Erbitux®)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-94
|
Rituximab (Rituxan®) for Non-Oncologic Indications
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00041
|
Rituximab (Rituxan®) for Non-Oncologic Indications
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-95
|
Belatacept (Nulojix®)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00049
|
Belatacept (Nulojix®)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-96
|
Ado-trastuzumab emtansine (Kadcyla®)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00056
|
Ado-trastuzumab emtansine (Kadcyla®)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-97
|
Rilonacept (Arcalyst®)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00073
|
Rilonacept (Arcalyst®)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-98
|
Bendamustine Hydrochloride
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00079
|
Bendamustine Hydrochloride
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-99
|
Elotuzumab (Empliciti™)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00083
|
Elotuzumab (Empliciti™)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-100
|
Interferon gamma-1b (Actimmune®)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00084
|
Interferon gamma-1b (Actimmune®)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-101
|
Ixabepilone (Ixempra®)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00085
|
Ixabepilone (Ixempra®)
|
|
6/28/2018
|
Conversion New
|
CG-DRUG-102
|
Olaratumab (Lartruvo™)
|
|
6/28/2018
|
Conversion Archived
|
DRUG.00097
|
Olaratumab (Lartruvo™)
|
|
6/28/2018
|
Conversion New
|
CG-MED-72
|
Hyperthermia for Cancer Therapy
|
|
6/28/2018
|
Conversion Archived
|
MED.00026
|
Hyperthermia for Cancer Therapy
|
|
6/28/2018
|
Conversion New
|
CG-SURG-76
|
Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
|
|
6/28/2018
|
Conversion Archived
|
SURG.00001
|
Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
|
|
6/28/2018
|
Conversion New
|
CG-SURG-77
|
Refractive Surgery
|
|
6/28/2018
|
Conversion Archived
|
SURG.00009
|
Refractive Surgery
|
|
6/28/2018
|
Conversion New
|
CG-SURG-78
|
Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
|
|
6/28/2018
|
Conversion Archived
|
SURG.00065
|
Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
|
|
6/28/2018
|
Conversion New
|
CG-SURG-79
|
Implantable Infusion Pumps
|
|
6/28/2018
|
Conversion Archived
|
SURG.00068
|
Implantable Infusion Pumps
|
|
6/28/2018
|
Conversion New
|
CG-SURG-80
|
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
|
|
6/28/2018
|
Conversion Archived
|
RAD.00011
|
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
|
|
|
|
|
|
|
6/6/2018
|
Revised
|
DRUG.00046
|
Ipilimumab (Yervoy®)
|
|
5/10/2018
|
Revised
|
DRUG.00047
|
Brentuximab Vedotin (Adcetris®)
|
|
11/1/2018
|
Revised
|
DRUG.00050
|
Eculizumab (Soliris®)
|
|
5/10/2018
|
Revised
|
DRUG.00053
|
Carfilzomib (Kyprolis®)
|
|
6/6/2018
|
Revised
|
DRUG.00071
|
Pembrolizumab (Keytruda®)
|
|
6/6/2018
|
Revised
|
DRUG.00075
|
Nivolumab (Opdivo®)
|
|
5/10/2018
|
Revised
|
DRUG.00076
|
Blinatumomab (Blincyto®)
|
|
6/6/2018
|
Revised
|
DRUG.00104
|
Nusinersen (SPINRAZA®) Previous title: Nusinersen (SPINRAZA™)
|
|
11/1/2018
|
Revised
|
DRUG.00111
|
Monoclonal Antibodies to Interleukin-23 Previous title: Guselkumab (Tremfya™)
|
|
6/6/2018
|
Revised
|
GENE.00012
|
Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
|
|
6/6/2018
|
Revised
|
GENE.00026
|
Cell-Free Fetal DNA-Based Prenatal Testing
|
|
5/10/2018
|
Revised
|
SURG.00026
|
Deep Brain, Cortical, and Cerebellar Stimulation
|
|
6/6/2018
|
Revised
|
SURG.00032
|
Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
|
|
11/1/2018
|
Revised
|
CG-ADMIN-02
|
Clinically Equivalent Cost Effective Services – Targeted Immune Modulators
|
|
6/6/2018
|
Revised
|
CG-DRUG-05
|
Recombinant Erythropoietin Products
|
|
6/6/2018
|
Revised
|
CG-DRUG-09
|
Immune Globulin (Ig) Therapy
|
|
6/6/2018
|
Revised
|
CG-DRUG-16
|
White Blood Cell Growth Factors
|
|
11/1/2018
|
Revised
|
CG-DRUG-25
|
Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
|
|
5/10/2018
|
Revised
|
CG-DRUG-50
|
Paclitaxel, protein bound (Abraxane®)
|
|
6/6/2018
|
Revised
|
CG-DRUG-60
|
Gonadotropin Releasing Hormone Analogs for Treatment of Oncologic Indications
|
|
6/6/2018
|
Revised
|
CG-DRUG-62
|
Fulvestrant (FASLODEX®)
|
|
6/6/2018
|
Revised
|
CG-DRUG-73
|
Denosumab (Prolia®, Xgeva®)
|
|
11/1/2018
|
Revised
|
CG-DRUG-78
|
Antihemophilic Factors and Clotting Factors
|
|
|
|
|
|
|
6/6/2018
|
Reviewed
|
DRUG.00067
|
Ramucirumab (Cyramza®)
|
|
6/6/2018
|
Reviewed
|
DRUG.00109
|
Durvalumab (Imfinzi®) Previous title: Durvalumab (Imfinzi™)
|
|
6/6/2018
|
Reviewed
|
GENE.00009
|
Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
|
|
6/6/2018
|
Reviewed
|
GENE.00023
|
Gene Expression Profiling of Melanomas
|
|
6/6/2018
|
Reviewed
|
GENE.00025
|
Molecular Profiling for the Evaluation of Malignant Tumors
|
|
6/6/2018
|
Reviewed
|
MED.00077
|
In Vivo Analysis of Gastrointestinal Lesions
|
|
6/6/2018
|
Reviewed
|
OR-PR.00003
|
Microprocessor Controlled Lower Limb Prosthesis
|
|
6/6/2018
|
Reviewed
|
SURG.00132
|
Drug-Eluting Devices for Maintaining Sinus Ostial Patency
|
|
6/6/2018
|
Reviewed
|
SURG.00148
|
Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
|
|
6/6/2018
|
Reviewed
|
TRANS.00031
|
Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
|
|
No change
|
Reviewed
|
CG-MED-35
|
Retinal Telescreening Systems
|
|
6/6/2018
|
Reviewed
|
CG-REHAB-05
|
Occupational Therapy
|
|
|
|
|
Cardiology Guidelines
|
|
By AIM
|
AIM
|
|
Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography
|
|
By AIM
|
AIM
|
|
Clinical Appropriateness Guidelines: Percutaneous Coronary Intervention
|
|
|
|
|
Radiology Guidelines
|
|
By AIM
|
AIM
|
|
Clinical Appropriateness Guidelines: Advanced Imaging
|
|
|
|
|
Radiation Oncology Guidelines
|
|
By AIM
|
AIM
|
|
Clinical Appropriateness Guidelines: Radiation Oncology: Proton Beam Therapy Guidelines
|
|
|
|
|
|
|
11/1/2018
|
Archived
|
THER-RAD.00002
|
Proton Beam Radiation Therapy
|
|
|
|
|
|
|
6/6/2018
|
Annual Review
|
DME.00022
|
Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
|
|
6/6/2018
|
Annual Review
|
DRUG.00088
|
Atezolizumab (Tecentriq®)
|
|
6/6/2018
|
Annual Review
|
DRUG.00107
|
Avelumab (Bavencio®)
|
|
6/6/2018
|
Annual Review
|
DRUG.00110
|
Inotuzumab ozogamicin (Besponsa®)
|
|
6/6/2018
|
Annual Review
|
GENE.00001
|
Genetic Testing for Cancer Susceptibility
|
|
6/6/2018
|
Annual Review
|
GENE.00002
|
Preimplantation Genetic Diagnosis Testing
|
|
6/6/2018
|
Annual Review
|
GENE.00005
|
BCR-ABL Mutation Analysis
|
|
11/1/2018
|
Annual Review
|
GENE.00006
|
Epidermal Growth Factor Receptor (EGFR) Testing
|
|
6/6/2018
|
Annual Review
|
GENE.00007
|
Cardiac Ion Channel Genetic Testing
|
|
6/6/2018
|
Annual Review
|
GENE.00016
|
Gene Expression Profiling for Colorectal Cancer
|
|
6/6/2018
|
Annual Review
|
GENE.00017
|
Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)
|
|
6/6/2018
|
Annual Review
|
GENE.00031
|
Genetic Testing for PTEN Hamartoma Tumor Syndrome
|
|
6/6/2018
|
Annual Review
|
GENE.00038
|
Genetic Testing for Statin-Induced Myopathy
|
|
6/6/2018
|
Annual Review
|
GENE.00040
|
Genetic Testing for CHARGE Syndrome
|
|
6/6/2018
|
Annual Review
|
GENE.00045
|
Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
|
|
6/6/2018
|
Annual Review
|
LAB.00003
|
In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
|
|
6/6/2018
|
Annual Review
|
LAB.00011
|
Analysis of Proteomic Patterns
|
|
6/6/2018
|
Annual Review
|
LAB.00015
|
Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
|
|
6/6/2018
|
Annual Review
|
LAB.00025
|
Topographic Genotyping
|
|
6/6/2018
|
Annual Review
|
MED.00024
|
Adoptive Immunotherapy and Cellular Therapy
|
|
6/6/2018
|
Annual Review
|
MED.00053
|
Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting
|
|
6/6/2018
|
Annual Review
|
MED.00087
|
Imaging Techniques for Screening and Identification of Cervical Cancer
|
|
6/6/2018
|
Annual Review
|
MED.00102
|
Ultrafiltration in Decompensated Heart Failure
|
|
6/6/2018
|
Annual Review
|
MED.00104
|
Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
|
|
6/6/2018
|
Annual Review
|
MED.00105
|
Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
|
|
6/6/2018
|
Annual Review
|
MED.00111
|
Intracardiac Ischemia Monitoring
|
|
6/6/2018
|
Annual Review
|
MED.00112
|
Autonomic Testing
|
|
6/6/2018
|
Annual Review
|
MED.00118
|
Continuous Monitoring of Intraocular Pressure
|
|
6/6/2018
|
Annual Review
|
MED.00119
|
High Intensity Focused Ultrasound (HIFU) for Oncologic Indications
|
|
6/6/2018
|
Annual Review
|
MED.00124
|
Tisagenlecleucel (Kymriah™)
|
|
6/6/2018
|
Annual Review
|
OR-PR.00004
|
Partial-Hand Myoelectric Prosthesis
|
|
6/6/2018
|
Annual Review
|
RAD.00001
|
Computed Tomography to Detect Coronary Artery Calcification
|
|
6/6/2018
|
Annual Review
|
RAD.00022
|
Magnetic Resonance Spectroscopy (MRS)
|
|
6/6/2018
|
Annual Review
|
RAD.00040
|
PET Scanning Using Gamma Cameras
|
|
6/6/2018
|
Annual Review
|
RAD.00043
|
Computed Tomography Scans for Lung Cancer Screening
|
|
6/6/2018
|
Annual Review
|
RAD.00054
|
MRI of the Bone Marrow
|
|
6/6/2018
|
Annual Review
|
RAD.00059
|
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord
|
|
6/6/2018
|
Annual Review
|
RAD.00066
|
Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy
|
|
6/6/2018
|
Annual Review
|
SURG.00016
|
Stereotactic Radiofrequency Pallidotomy
|
|
6/6/2018
|
Annual Review
|
SURG.00022
|
Lung Volume Reduction Surgery
|
|
6/6/2018
|
Annual Review
|
SURG.00072
|
Lysis of Epidural Adhesions
|
|
6/6/2018
|
Annual Review
|
SURG.00075
|
Intervertebral Stabilization Devices
|
|
6/6/2018
|
Annual Review
|
SURG.00107
|
Prostate Saturation Biopsy
|
|
6/6/2018
|
Annual Review
|
SURG.00113
|
Artificial Retinal Devices
|
|
6/6/2018
|
Annual Review
|
SURG.00124
|
Carotid Sinus Baroreceptor Stimulation Devices
|
|
6/6/2018
|
Annual Review
|
SURG.00137
|
Focused Microwave Thermotherapy for Breast Cancer
|
|
6/6/2018
|
Annual Review
|
SURG.00139
|
Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
|
|
6/6/2018
|
Annual Review
|
SURG.00147
|
Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
|
|
6/6/2018
|
Annual Review
|
SURG.00149
|
Percutaneous Ultrasonic Ablation of Soft Tissue
|
|
6/6/2018
|
Annual Review
|
TRANS.00016
|
Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
|
|
6/6/2018
|
Annual Review
|
TRANS.00025
|
Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-04
|
Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®), and Direct Thrombin Inhibitors in the Outpatient Setting
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-08
|
Enzyme Replacement Therapy for Gaucher Disease
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-34
|
Docetaxel (Docefrez™, Taxotere®)
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-41
|
Zoledronic acid
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-46
|
Fosaprepitant (Emend®)
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-48
|
Azacitidine (Vidaza®)
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-49
|
Doxorubicin Hydrochloride Liposome Injection
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-51
|
Romidepsin (Istodax®)
|
|
6/6/2018
|
Annual Review
|
CG-DRUG-53
|
Drug Dosage, Frequency, and Route of Administration
|
|
6/6/2018
|
Annual Review
|
CG-MED-37
|
Intensive Programs for Pediatric Feeding Disorders
|
|
6/6/2018
|
Annual Review
|
CG-MED-45
|
Transrectal Ultrasonography
|
|
6/6/2018
|
Annual Review
|
CG-MED-50
|
Visual, Somatosensory and Motor Evoked Potentials
|
|
6/6/2018
|
Annual Review
|
CG-SURG-17
|
Trigger Point Injections
|
|
6/6/2018
|
Annual Review
|
CG-SURG-18
|
Septoplasty
|
|
6/6/2018
|
Annual Review
|
CG-SURG-30
|
Tonsillectomy for Children with or without Adenoidectomy
|
|
6/6/2018
|
Annual Review
|
CG-SURG-36
|
Adenoidectomy
|
|
6/6/2018
|
Annual Review
|
CG-SURG-40
|
Cataract Removal Surgery for Adults
|
|
6/6/2018
|
Annual Review
|
CG-SURG-46
|
Myringotomy and Tympanostomy Tube Insertion
|
|
6/6/2018
|
Annual Review
|
CG-SURG-55
|
Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
|
|
|
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OrthoNet
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By OrthoNet
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OrthoNet - Annual Review
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Physical and Occupational Therapy Management Programs OrthoNet maintains 64 distinct guidelines addressing the medical necessity of physical therapy (PT) and occupational therapy (OT), which includes the following atypical guidelines; Bell’s Palsy, Congenital Infantile Muscular Torticollis, General Neuromuscular Criteria, and Vestibular Disorders.
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CODING
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11/1/2018
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Coding Update of Existing Document
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CG-DRUG-89
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Implantable and Extended-Release Buprenorphine-Containing Products
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Bundled Services and Supplies – Professional
Beginning with dates of service on or after November 1, 2018, BCBSGa has added information to Section 1 of our policy that charges for copies of x-rays or DVDs are considered always bundled services and not eligible for separate reimbursement.
Once per Lifetime Procedures – Professional
BCBSGa’s Once per Lifetime Procedures policy received a biennial review and we are removing modifier 58 from the policy. Modifier 58 is used to report a staged or related procedure by the same physician during the postoperative period and would not be used for a once per lifetime procedure if that procedure was previously performed on the patient. BCBSGa is working with Accordant Health Services to provide targeted disease management services for members with rare medical conditions, including:
- Epilepsy (Seizures)
- Rheumatoid Arthritis (RA)
- Human Immunodeficiency Virus (HIV)
- Multiple Sclerosis (MS)
- Crohn's Disease (CD)
- Ulcerative Colitis (UC)
- Parkinson's Disease (PD)
- Systemic Lupus Erythematosus (SLE or Lupus)
- Myasthenia Gravis (MG)
- Sickle Cell Disease (SCD)
- Cystic Fibrosis (CF)
- Hemophilia
- Scleroderma
- Polymyositis
- Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
- Amyotrophic Lateral Sclerosis (ALS)
- Dermatomyositis
- Gaucher Disease
Members in your care who may benefit from additional outreach and information may receive letters or phone calls from AccordantCare and BCBSGa. In the course of performing these activities, a nurse may contact you or your facility to obtain member information and/or AccordantCare may request medical information about BCBSGa members. AccordantCare and BCBSGa also will let you know of any health changes that may require your attention.
If you would like to refer a member to this program, please contact AccordantCare at:
Phone or Fax: 1-866-247-1150
Web: https://referral.accordant.com
Plan name: AnthemReferrals Password: ref1088Anthem Effective for dates of service on and after November 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy clinical site of care review process.
BCBSGa’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
View the Clinical Site of Care drug list and Clinical Site of Care prior authorization clinical review FAQs for more information.
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Medical Policy or
Clinical Guideline
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Drug
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Code
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CG-DRUG-78
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HemlibraTM
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Q9995
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CG-DRUG-89
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SublocadeTM
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Q9991
Q9992
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CG-DRUG-89
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Probuphine®
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J0570
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CG-DRUG-05
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Retacrit®
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Q5106
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Effective with dates of service on and after October 1, 2018, and in accordance with BCBSGa’s Pharmacy and Therapeutic (P&T) process, BCBSGa will update its drug lists that support Commercial health plans.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here. BCBSGa accepts electronic medication prior authorization requests for commercial health plans. This feature reduces processing time and helps determine coverage quicker. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.
Electronic prior authorization (ePA) offers many benefits:
- More efficient review process
- Ability to identify if a prior authorization is required
- Able to see consolidated view of ePA submissions in real time
- Faster turnaround times
- A renewal program that allows for improved continuity of care for members with maintenance medication
- Prior authorizations are preloaded for the provider before the expiration date.
Providers can submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.
While ePA helps streamline the prior authorization process, providers can also initiate a new prior authorization request by fax or phone. Please note, the contact numbers for the following plans will change effective September 1, 2018.
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Market
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New fax number
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New phone number
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Medicare
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844-521-6938
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833-293-0661
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GA off the exchange
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844-512-9002
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833-293-0659
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GA on the exchange
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844-512-9003
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833-293-0660
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If you have other questions, please contact the provider service number on the member ID card.
Beginning with prescriptions filled on and after September 1, 2018, BCBSGa will apply a daily morphine equivalent dosing limit of 90mg. This change is part of our continued efforts to help improve patient safety and reduce the misuse and abuse of opioid analgesics.
Current users of short-acting or long-acting opioid analgesics will only be impacted by this change should they have a change in their prescription requesting an increase in dosage that exceeds the new limitation.
Members with a diagnosis of cancer related pain or a diagnosis of a terminal condition, and receiving palliative care and needing short-acting or long-acting opioid analgesics, will automatically be approved through the prior authorization process.
Please note, this update does not apply to Medicare plans.
Visit the pharmacy information page for details on prior authorization criteria, or any other requirements, restrictions or limitations that may apply.
For more information, please contact the provider service number on the back of the member ID card. For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit bcbsga.com/provider and select “ Pharmacy Information”. The commercial drug list is reviewed and updates are posted to the web site quarterly (the first of the month for January, April, July and October). To locate “Marketplace Select Formulary” and pharmacy information, go to Customer Support, select your state, Download Forms and choose “Select Drug List.” Click the following links for the Federal Employee Program formulary Basic Option and Standard Options. These drug lists are also reviewed and updated regularly as needed. Effective for dates of service on and after November 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our prior authorization review process.
BCBSGa’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
The following clinical guidelines or medical policies will be effective November 1, 2018:
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Medical Policy or Clinical Guideline
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Code
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Drug
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Comments
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DRUG.00098
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C9031
A9699
J9999
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Lutathera®
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New Policy
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DRUG.00111
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J3590
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IlumyaTM
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New Drug to Existing Policy
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CG-DRUG-05
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Q5105
Q5106
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Retacrit®
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New Drug to Existing Guideline
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CG-DRUG-16
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J3590
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FulphilaTM
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New Drug to Existing Guideline
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We have several incentive programs this year to encourage Medicare Advantage members to obtain preventive screenings. Members may be rewarded when they complete their annual routine physical with their PCP. Eligible members will receive a gift card for competing their screening mammogram, a colorectal cancer screening or their diabetes retinal exam. Your member may ask that you confirm these screenings. Effective for dates of service on and after Oct. 31, 2018, BCBSGa will transition from using the InterQual (IQ) LOC: Rehabilitation and LOC: Subacute/SNF guidelines to using Milliman Care Guideline (MCG) Recovery Facility Care guidelines to review prior authorization requests for inpatient rehabilitation and skilled nursing facility services.
In addition, BCBSGa will transition from using the Interqual (IQ) LOC: Home Care to using Anthem Clinical UM Guidelines CG-MED-23 Home Health, CG-REHAB-04 Physical Therapy, CG-REHAB-05 Occupational Therapy or CG-REHAB-06 Speech-Language Pathology Services.
Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com. Contracted and non-contracted providers who are unable to access Availity may call our Provider Services at the number on the back of the member’s ID card for prior authorization requirements. To help our members receive the DME equipment they need and help ensure no disruption in care, it is important to document that the physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. Additional details on this requirement and other information that will help ensure that your prior authorization request for a wheelchair is processed efficiently will be available at Important Medicare Advantage Updates at bcbsga.com/medicareprovider. BCBSGa accepts electronic medication prior authorization requests for Medicare plans. This feature reduces processing time and helps determine coverage more quickly. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.
Electronic prior authorization (ePA) offers many benefits:
- More efficient review process
- Ability to identify if a prior authorization is required
- Able to see consolidated view of ePA submissions in real time
- Faster turnaround times
- A renewal program that allows for improved continuity of care for members with maintenance medication
- Prior authorizations are preloaded for the provider before the expiration date.
Submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.
While ePA helps streamline the prior authorization process, if you must initiate a new PA request by fax or phone, please note that the contact numbers for Medicare Prior Authorization will change Sept. 1, 2018.
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Effective Sept. 1, 2018
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New Fax Number
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New Phone Number
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Medicare Prior Authorizations
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844-521-6938
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833-293-0661
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If you have other questions, please contact the provider service number on the back of the member ID card. The Centers for Medicare & Medicaid Services recently issued regulations related to opioid analgesics to help improve patient safety and reduce the misuse of opioid analgesics.
Beginning Jan. 1, 2019, all short- and long-acting opioids will reject at the point of sale if prescribed for more than seven days. This edit applies to members who do not have an opioid prescription in the previous 60 days. The edit excludes members with cancer or members in hospice.
These edits are intended to allow those with intractable pain an opportunity to maintain their pain control while helping reduce the potential for misuse or addiction among those who are experiencing acute pain. MyDiversePatients.com features robust educational resources to help providers address health care disparities. You will find:
- CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.
- Real life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
Visit MyDiversePatients.com today to learn more.
If you are not using an electronic submission option, we ask that you use the following address for FEP paper claims, correspondence and grievance and appeals:
Federal Employee Program
PO Box 105557
Atlanta, GA 30348-5557
If you have any questions, contact FEP customer service at 800-282-2473. |