• Revised Clinical Indications for admission and added examples for:
  • Aggressive hydration needs that cannot be managed in an infusion center
  • Prolonged marrow suppression
• Added Regimens that cannot be managed as an outpatient with examples

View the summary of MCG 23RD edition customizations.

For questions, please contact the provider service number on the back of the member's ID card.

Prostate Cancer: Added criteria for the appropriate use of PET-CT with the radiotracers Axumin and 11-Choline, establishing the position of this test in the care continuum for prostate cancer primarily related to biochemical recurrence

Neuroendocrine Tumors: Added criteria for the appropriate use of PET-CT with the radiotracer DOTA-TATE , establishing the position of this test in the care continuum for neuroendocrine tumors

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

• Access AIM’s ProviderPortal_SM 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.

• Sinonasal cancer: Added criteria and diagnosis codes for locally advanced sinonasal cancer when tumor involves base of skull and proton beam therapy is needed to spare orbit, optic nerve, optic chiasm, or brainstem
• Ocular Melanoma: Removed tumor size restrictions for treating melanoma of the uveal tract
• Pediatric tumors: Clarified proton beam therapy appropriate for all pediatric tumors requiring radiation therapy

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

• Access AIM’s ProviderPortal_SM 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.

Please note, this program does not apply to FEP or National Accounts

• Colorectal cancer, germ cell tumors, kidney cancer, multiple myeloma, prostate cancer and cancers of unknown primary/cancers not otherwise specified,
• Added new sections on hepatobiliary cancer and suspected metastases
• Added allowance for MRI and/or MRCP for diagnostic workup of hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma
• Added allowance for PET “When standard imaging prior to planned curative surgery for cholangiocarcinoma has been performed and has not demonstrated metastatic disease”

• Brain, Head and Neck: Aneurysm–intracranial,  Aneurysm–extracranial, Arteriovenous malformation (AVM) and fistula (AVF), Fibromuscular dysplasia, Hemorrhage–intracranial, Stenosis or occlusion–extracranial, Stenosis or occlusion–intracranial, stroke and Venous thrombosis or compression–intracranial
• Chest: Acute aortic syndrome, Aortic aneurysm, Pulmonary artery hypertension
• Abdomen and Pelvis: Acute aortic syndrome, Aneurysm of the abdominal aorta or iliac arteries, Hematoma/hemorrhage within the abdomen or unexplained hypotension, Renal artery stenosis (RAS)/Renovascular hypertension, Venous thrombosis or compression–intracranial, Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
• Upper Extremity: Peripheral arterial disease, Venous thrombosis or occlusion
• Lower Extremity: Added physiologic testing for peripheral arterial disease and further defined indications for classic presenting symptoms of lower extremity peripheral arterial disease
• Added arterial ultrasound guideline content
• Aligned peripheral arterial ultrasound with advanced vascular imaging criteria

• Blood Pool Imaging: Changes address appropriate evaluation and surveillance of LV function in patients following cardiac transplantation. Additional language is more restrictive based on the literature and aligns with the resting transthoracic echocardiography guideline.
• Cardiac CT: Quantitative evaluation of coronary artery calcification has been revised with new more expansive language based on review of the literature.

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

• Access AIM’s ProviderPortal_SM 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.

Please continue to check Important Medicare Advantage Updates at bcbsga.com/medicareprovider for the latest Medicare Advantage information, including:

• Notice of change in Medicare Advantage non-PCP reimbursement status
• Hearing Care Solutions now serves individual Medicare Advantage members in CT, NY, VA and all Group Retiree Solutions members

75743MUPENMUB

Anthem Blue Cross and Blue Shield offers special needs plans (SNPs) to people eligible for either Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNPs include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums. As you are aware, CMS regulations protect SNP members from balance billing.

Providers who are contracted for SNPs are required to take annual training to stay current on plan benefits and requirements, including coordination-of-care and model-of-care elements. Providers contracted for our SNPs received notices in the first quarter of 2019 containing information for online, self-paced training through our training site hosted by SkillSoft. Each provider contracted for our SNPs is required to complete this annual training and select the attestation stating they have completed the training. Attestations can be completed by individual providers or at the group level with one signature.

Currently, providers submit various pre-service requests to AIM Specialty Health® (AIM). As part of our ongoing quality improvement efforts for outpatient diagnostic imaging services, cardiac procedures and sleep studies, AIM may request documentation to support the clinical appropriateness of certain requests.

When requested, providers should verify information by submitting documentation from the medical record and/or participating in a pre-service consultation with an AIM physician reviewer. If medical necessity is not supported, the request may be denied as not medically necessary.

Should you have any questions, please call the Provider Services number on the back of the member ID card.

Click here for additional information about the unspecified diagnosis code update.

New Policy

Drug Screen Testing

(Policy 19-001, effective 10/01/19)

Anthem Blue Cross and Blue Shield (Anthem) Medicare Advantage allows reimbursement for presumptive and definitive drug screening services. In certain circumstances, Anthem Medicare Advantage allows reimbursement for presumptive drug testing by instrumented chemistry analyzers and definitive drug screening services for the same member provided on the same day by a reference laboratory.

Definitive drug testing may be done to confirm the results of a negative presumptive test or to identify substances when there is no presumptive test available. Provider’s documentation and member’s medical records should reflect that the test was properly ordered and support that the order was based on the result of the presumptive test.

In the event a reference lab (POS = 81) performs both presumptive and definitive tests on the same date of service, records should reflect that the ordering/treating provider issued a subsequent order for definitive testing based on the results of the presumptive tests.

For additional information, refer to the Drug Screen Testing reimbursement policy at anthem.com/medicareprovider.

You may have already noticed new additions to service types, including:

• Medically related transportation
• Long-term care
• Acupuncture
• Respite care
• Dermatology
• Sleep study therapy (found under diagnostic medical)
• Allergy testing

Note, although there is an extensive list of available benefit types available when submitting an eligibility and benefits request, these types do vary by payer. 

Here are some important points to remember when selecting service types:

• The benefit/service type field is populated with the last benefit type you selected. If you don’t see a specific benefit in the results, submit a new request and select the specific benefit type/service code.
• You have the ability to inquire about 50 patients at one time using the Add Multiple Patients feature.