 Provider News GeorgiaAugust 2022 Anthem Provider News - GeorgiaAccording to the American Medical Association (AMA) Current Procedural Terminology ® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after 30-day notice, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M.
If you have questions on this program, contact your contract manager or Provider Experience representative.
Material adverse change (MAC)
AIM Specialty Health®
AIM Specialty Health®, a separate company, is a nationally recognized leader delivering specialty benefits management on behalf of Anthem for certain health plan members. Determine if prior authorization is needed for a Georgia Anthem member by visiting the “Medical Policy and Clinical UM Guidelines” page on our provider website or by calling the prior authorization 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 website 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
- Rehabilitative services
- Outpatient sleep testing and therapy services
- Cancer care quality program
- Musculoskeletal (for fully insured)
- Upper gastrointestinal endoscopy in adults, and site of care for certain surgical services
For more details on these programs, please visit the AIM website. Clicking the previous links will direct you 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.
Eligibility and benefits
Verify eligibility and benefits on anthem.com/provider or by logging onto Availity.com. From the Patient Registration tab, run an Eligibility and Benefits Inquiry. Service preapproval is based on a 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 the verification of member eligibility and covered benefits. Except in the case of an emergency, failure to obtain approval prior to rendering the designated services listed above will result in denial of reimbursement.
The following services will be added to prior authorization for GA local members. Items marked with an ‘*’ may be reviewed by AIM.
|
Add to preapproval
|
|
DME.00046
Intermittent Abdominal Pressure Ventilation Devices
|
K1021
|
Add November 1, 2022
|
|
DME.00047
Rehabilitative Devices with Remote Monitoring
|
E1399
|
Add November 1, 2022
|
|
DME.00048
Virtual Reality-Assisted Therapy Systems
|
E1399
|
Add November 1, 2022
|
|
GENE.00059*
Hybrid Personalized Molecular Residual Disease Testing for Cancer
|
81479
|
Add November 1, 2022
|
|
LAB.00048
Pain Management Biomarker Analysis
|
0117U
|
Add November 1, 2022
|
|
MED.00139
Electrical Impedance Scanning for Cancer Detection
|
99199
|
Add November 1, 2022
|
|
TRANS.00039
Portable Normothermic Organ Perfusion Systems
|
32299, 47399, 33999, 53899
|
Add November 1, 2022
|
|
Codes added to existing preapproval documents
|
|
CG-SURG-61
Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
|
0673T, 61736, 61737, 60999
|
Add November 1, 2022
|
|
GENE.00023*
Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma
|
0315U
|
Add November 1, 2022
|
Submitting your updates promptly helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Using this form, you can update:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging that we received your request. See the Provider Maintenance Form for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Anthem Blue Cross and Blue Shield would like to remind you of the procedures to follow for inpatient claim denials:
- If claim is billed as inpatient bill type in error, a replacement bill xx7 is a replacement of the same type of bill (ex. x11 and x17, or x31 and x37; you may not use a x37 to replace a x11 or a x17 to replace a x31).
- If you are changing the bill type from inpatient to outpatient or outpatient to inpatient, the original claim will need to be voided by using a frequency type 8 (void).
- The void request must be submitted first by the provider, or in conjunction with a frequency type 1 (original) inpatient or outpatient claim before the outpatient bill type claim will be processed.
- This can be done electronically or with a provider adjustment request (PAR) form.
- Further instructions are included in the provider manual.
It is inappropriate to re-bill an outpatient claim when receiving a denial/upheld appeal response for ancillary services rendered in the inpatient setting for commercial polices. This includes, but is not limited to, emergency department, imaging, laboratory services, specialty pharmacy, and surgeries.
Claims should be coded and billed based on the medical record and the physician order.
For complete information on electronic claims processing procedures, visit the Electronic Data Interchange (EDI) page on our website.
Note: This update does not apply to Medicaid or Medicare Advantage.
As a reminder, Anthem Blue Cross and Blue Shield’s current Outpatient Prepay Itemized Bill Review Program reviews outpatient claims more than $100,000 billed at a percent of charge prior to reimbursement to ensure items and services included on the claim are reimbursable. We are expanding the prepay program launched in 2021 requiring an itemized bill review for all outpatient services as follows:
- Effective for dates of service on or after July 1, 2022, we will add host claims and ambulatory surgery centers (ASCs) in scope.
Now open for learning!
Access to training for Availity Essentials can be helpful when trying to master applications like claims attachments, authorizations, and eligibility and benefits. The Provider Learning Hub on Anthem.com is not only a new way to access training, but it also offers a new learning experience.
Short, easy to follow training videos with supporting resources are available on the Provider Learning Hub – no username and password required. Access it at your convenience and share your learnings with others on your teams. Handy filtering options enable you to quickly find what you are looking for including an option to save training to a "favorites" folder for easy access later. You will register for the Provider Learning Hub once. On future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today
Access the Provider Learning Hub using this link or from Anthem.com under Important Announcements on the home page.
Digital claims attachments expedite claims processing and payment. That’s why we have been hard at work making the digital attachment process easier, more intuitive and streamlined. Now you can add attachments directly to your claim by using the new Send Attachments feature from the Claims Status application on Availity.com.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time because there is no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and personal health information.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the Attachment Control Number, there are three options for submitting attachments:
- Through the Attachments Dashboard Inbox: From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox
- Through the 275 attachment: Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment
- Through the Availity.com application: From Availity.com, select the Claims & Payments tab to access a Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
If you submitted your claim through the Availity Essentials application:
- Simply submit your attachment with your claim
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments: From Availity.com, select the Claims & Payments tab and run a Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
Learn more about the Send Attachment feature
In collaboration with Availity Essentials, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status workflow. Sign up for a live webinar today:
Reductions in missed appointments are significant.
Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,[i]” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.
Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.
https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390
“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.
Telehealth and telephone visits with members after a behavioral health inpatient stay meet HEDIS® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.[ii]
The FUH HEDIS measure evaluates:
- Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.
Two areas of importance for this HEDIS measure are:
- The percentage of behavioral health inpatient discharges for which the member received follow-up within seven days after discharge
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.
These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the National Committee for Quality Assurance (NCQA) website.
This article was corrected on August 4, 2022. The original article included an incorrect effective date of July 1, 2022 for DME.00046, DME.00047, DME.00048, GENE.00059, LAB.00048, MED.00139, and TRANS.00039. The correct effective date for DME.00046, DME.00047, DME.00048, GENE.00059, LAB.00048, MED.00139, and TRANS.00039 is November 1, 2022.
The Medical Policy and Technology Assessment Committee (MPTAC) adopted the attached 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 Anthem Blue Cross and Blue Shield and all the medical policies are available on the Anthem provider website. Please note our medical policies now include NOC (not otherwise classified) codes to expedite the process of determining services that may require medical review. If you don’t 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–Friday from 8:00 a.m. to 7:00 p.m. Or send written requests (specifying medical policy or guideline of interest, your name and address to where information should be sent) to:
Anthem Blue Cross and Blue Shield
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 Georgia if included on the Georgia 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 MPTAC but not included in the Georgia 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.
Open the attached document titled GA medical policy and clinical guideline updates 7.1.2022 to view the new and/or revised medical policies and clinical guidelines adopted by the MPTAC.
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit fepblue.org > policies & guidelines.
Effective for dates of service on and after November 1, 2022, the following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
|
ING-CC-0068
|
Growth hormone
|
|
ING-CC-0087
|
Gamifant (emapalumab)
|
|
ING-CC-0107
|
Bevacizumab for non-ophthalmologic indications
|
|
ING-CC-0118
|
Radioimmunotherapy and somatostatin receptor targeted radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)
|
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
|
ING-CC-0153
|
Adakveo (crizanlizumab)
|
|
ING-CC-0215
|
Ketamine injection (Ketalar)
|
|
ING-CC-0216
|
Opdualag (nivolumab and relatlimab-rmbw)
|
Access the Clinical Criteria document information.
Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by the Medical Specialty Drug Review team for Anthem Blue Cross and Blue Shield. Drugs used for the treatment of oncology will be managed by AIM Specialty Health® (AIM).*
Visit the Drug Lists page at https://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.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
Material adverse change (MAC)
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Anthem’s medical specialty drug review team manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note
Currently, your patients may be receiving these medications without prior authorization. Effective November 1, 2022, you may be required to request prior authorization review for your patients’ continued use of these medications.
By including National Drug Code (NDC) on your claim, you will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical criteria
|
Drug
|
HCPCS or CPT® Code(s)
|
|
ING-CC-0216*
|
Opdualag (nivolumab and relatlimab-rmbw)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0002*
|
Releuko (filgrastim-ayow)
|
C9096
|
|
ING-CC-0118*
|
Pluvicto (lutetium lu 177 vipivotide tetraxetan)
|
A9699
|
|
ING-CC-0107*
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0072
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590
|
* Oncology use is managed by AIM.
Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Releuko
|
C9096
|
|
ING-CC-0107*
|
Non-preferred
|
Alymsys
|
C9399, J3490, J3590, J9999
|
*Oncology use is managed by AIM.
Courtesy notice
Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.
Quantity limit updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590
|
|