December 2021 Anthem Provider News - Georgia

Contents

AdministrativeCommercialDecember 1, 2021

Important information about utilization management

AdministrativeCommercialDecember 1, 2021

Importance of PCP after-hours messaging

AdministrativeCommercialDecember 1, 2021

Behavioral healthcare appointment access requirements

AdministrativeCommercialDecember 1, 2021

Outpatient system updates for 2022

AdministrativeCommercialDecember 1, 2021

Professional system updates for 2022

AdministrativeCommercialDecember 1, 2021

Coordination of care

AdministrativeCommercialDecember 1, 2021

Member rights and responsibilities

Medical Policy & Clinical GuidelinesCommercialDecember 1, 2021

Updates to AIM Advanced Imaging Clinical Appropriateness Guideline (MAC)

Medical Policy & Clinical GuidelinesCommercialDecember 1, 2021

Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guideline (MAC)

Medical Policy & Clinical GuidelinesCommercialDecember 1, 2021

Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines (MAC)

Products & ProgramsCommercialDecember 1, 2021

Case Management Program

Products & ProgramsCommercialDecember 1, 2021

Updated AIM musculoskeletal program site of care reviews delayed

State & FederalMedicare AdvantageDecember 1, 2021

Keep up with Medicare news

State & FederalMedicare AdvantageDecember 1, 2021

Somatus is your resource for kidney care management

State & FederalMedicare AdvantageDecember 1, 2021

2022 Medicare Advantage service area and benefit updates

State & FederalMedicare AdvantageDecember 1, 2021

Policy Update: Drug Screen Testing

State & FederalMedicare AdvantageDecember 1, 2021

Non-payment remittance advice enhancements

AdministrativeCommercialDecember 1, 2021

Important information about utilization management

Anthem Blue Cross and Blue Shield (Anthem) utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision-makers to encourage decisions resulting in under-utilization. Our medical policies are available on Anthem’s website at anthem.com.

 

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on the web. Just go to anthem.com, and select For Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies and Clinical UM Guidelines.

 

We work with providers to answer questions about the utilization management process and the authorization of care. Here’s how the process works:

  • Call us toll-free from 8:30 a.m. to 5:00 p.m., Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8:00 a.m. to 7:00 p.m. ET.
  • If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after 12 midnight will be returned the same business day.
  • Our associates will contact you about your UM inquiries during business hours unless otherwise agreed upon.

 

The following phone lines are for physicians and their staff. Members should call the customer service number on their health plan ID card.

To discuss UM Process and Authorizations

To Discuss Peer-to-Peer

UM Denials w/Physician

To Request UM Criteria

TTY/TDD

800 662-9023,

800 722-6614,

855-343-4851 or
855-343-4852

 

Transplant

800-824-0581

National Transplant

844-644-8101

FAX: 888-438-7051

 

Behavioral Health

800-292-2879

 

Autism

844 269 0538

 

University System of Georgia (USG)

800-233-5765

Behavioral Health

800-292-2879

 

State Health Benefit (SHBP)

Behavioral Health:

855 679-5725

 

FEP

800-860-2156

Fax: 800 732-8318 (UM)

Fax: 877 606-3807 (ABD)

877-771-9165

 

Behavioral Health

800-292-2879

 

Adaptive Behavioral Treatment

844-269-0538

 

University System of Georgia (USG)

877-771-9165

Behavioral Health

800-292-2879

 

State Health Benefit (SHBP)

Medical:

855 668 6442

Behavioral Health:

855 679-5725

 

FEP

800-860-2156

800 662-9023,

800 722-6614,

855-343-4851 or
855-343-4852

 

Behavioral Health

800-292-2879

 

University System of Georgia (USG)

800-233-5765

Behavioral Health

800-292-2879

 

State Health Benefit (SHBP)  Medical:

855 668 6442

Behavioral Health:

855 679-5725

 

FEP

800-860-2156

Fax: 800 732-8318 (UM)

Fax: 877 606-3807 (ABD)

711, or

TTY: 800-255-0056

Voice: 800-255-0135

 


For language assistance, members can simply call the customer service phone number on the back of their ID card and a representative will be able to assist them.

 

Our utilization management associates identify themselves to all callers by first name, title, and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.


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AdministrativeCommercialDecember 1, 2021

Importance of PCP after-hours messaging

The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem Plans assessed fell short of the expectation of having a live person or a directive in place after hours.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

  • inaccurate provider information in Anthem's demographic database to allow assessment of the after-hours messaging
  • no voicemail or messaging at all
  • voicemail not reflecting the practitioner’s name, and/or
  • calls being auto forwarded with no identification, no voicemail or messaging

 

To help both your patients’ and Anthem's ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

 

What does this mean for our members and your patients? The annual member experience survey of Anthem enrollees indicated of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these three steps:

  1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
  2. Be sure to turn on the messaging mechanism when you leave the office.
  3. Be sure you are using the acceptable messaging for compliance with your contract.

 

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

 

Emergency situations

Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER.  

 

Urgent situations

Compliant responses for urgent needs after hours:

  • Live person, via a service or hospital, advises practitioner or on call practitioner is available and connects.
  • Live person or recording directs caller/patient to Urgent Care, ER or call 911.

 

Non-compliant responses for urgent needs after hours:

  • No provision for after-hours accessibility.
  • Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. (Not a direct connection to their practitioner.)

 

Is your practice compliant?

 

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AdministrativeCommercialDecember 1, 2021

Behavioral healthcare appointment access requirements

The annual behavioral health access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded during the first through third quarters of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine follow-ups.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e. incorrect or non-working phone numbers; practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only, or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.

 

The primary appointment type not meeting compliance is consistently obtaining the initial routine appointment. This is the initial conversation with a professional after the intake assessment for a new patient for a non-urgent condition. Please refer to compliant timeframe and explanation below.

 

To be compliant, per the Provider Manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:

  • Non-life-threatening emergency – The patient must meet with their BH practitioner, another practitioner in the practice or a covering practitioner within 6 hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
    • Explanation - These calls concern members in acute distress whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
  • Urgent – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 48 hours.
    • Explanation - These calls are non-emergent with significant psychological distress when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
  • Initial routine office visit – A new patient must meet with a designated BH practitioner or another equivalent practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating practitioner.
    • Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms which presents no immediate distress, and can wait to schedule an appointment without any adverse outcomes.
  • Routine office visit – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 30 calendar days.
    • Explanation - These calls concern existing members to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
  • BH follow-up appointment after discharge – The patient must meet with their practitioner or another practitioner in the practice within 7 calendar days.
  • Explanation – These calls concern members being released from inpatient psychiatric hospital care requesting a follow-up appointment to evaluate what has taken place since release, including med management.

 

1481-1221-PN-GA

AdministrativeCommercialDecember 1, 2021

Chlamydia is asymptomatic. Only through screening will we know for sure.

Talking to a teenager about Chlamydia can be difficult. But, if untreated, this typical teenager could develop Pelvic Inflammatory Disease (PID) or worse, infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. For a free Chlamydia How-To  Implementation Guide for Healthcare Providers, visit the National Chlamydia Coalition website at  chlamydiacoalition.org.


One of the largest growing populations for Chlamydia are teens aged 15 to 24. Through annual screening – a simple urine test in your office or in an off-site lab – teens can maintain good health.

Chlamydia Screening in Women (CHL): HEDIS® recommends annual screenings for teens starting at age 16 and for women up to aged 24. Sexually active teens and women should be tested each calendar year and for women who have:

  • Made comments or talked to you about sexual relations
  • Been pregnancy tested
  • Been prescribed birth control (even if used for acne treatment)
  • Received Gynecological services
  • A history of sexually transmitted diseases
  • A history of sexual assault or abuse

Description

CPT Codes

Chlamydia tests

87110, 87270, 87320, 87490, 87491, 87492, 87810

Pregnancy test exclusion

81025, 84702, 84703



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ATTACHMENTS (available on web): 1471 image.jpg (jpg - 0.08mb)

AdministrativeCommercialDecember 1, 2021

Outpatient system updates for 2022

As a reminder, Anthem Blue Cross and Blue Shield (Anthem) will continue to upgrade our claim editing software for outpatient facility services monthly throughout 2022, with most updates occurring quarterly. These upgrades will include, but are not limited to:

 

  • Addition of new and revised codes (for example CPT, HCPCS, ICD-10, modifiers, and revenue codes) and their associated edits
  • Updates related to the appropriate use of various code combinations, which can include, but are not limited to:
    • Procedure code to revenue code
    • HCPCS to revenue code
    • Type of bill to procedure code
    • Type of bill to HCPCS code
    • Procedure code to modifier
    • HCPCS to modifier
  • Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
  • Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC)

 

1459-1221-PN-GA

AdministrativeCommercialDecember 1, 2021

Prepare for the Consolidated Appropriations Act: Keep your provider directory information up to date

As we announced in the October edition of Provider News, Anthem Blue Cross and Blue Shield (Anthem) is working to comply with the requirements of the Consolidated Appropriations Act, or CAA.


Improving the accuracy of provider directory information

As part of the CAA, soon providers will be asked to verify their online provider directory information on a regular basis to help ensure Anthem members can locate the most current information for in-network providers and facilities. It is important that you keep your information up to date. Here’s what you can do now:

  • Review your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to anthem.com/provider, then under Provider Overview, choose Find Care.

 

  • Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
    • add/change an address location
    • name change
    • 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 receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

 

Consolidated Appropriations Act implementation

The Consolidated Appropriations Act does not preempt state law requirements. This means that the CAA applies in addition to any state law requirements of providers to update their provider directory information.

On August 20, 2021, the Tri-Agencies (Departments of Labor, Health and Human Services and the Treasury) announced that regulations to implement the provider directory requirements would be issued on or after January 1, 2022. Health plans are expected to implement the provider directory requirements based on a good faith, reasonable interpretation of the requirements by January 1, 2022, with a primary focus on ensuring that members who rely on provider directory information that inaccurately depicts a provider’s network status are only liable for in-network cost-sharing amounts. Anthem is moving forward with compliance of this good faith, reasonable interpretation of the requirements while awaiting additional regulatory guidance.

 

Watch for upcoming editions of Provider News in 2022 for updates on our ongoing efforts to comply with the CAA requirements.


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AdministrativeCommercialDecember 1, 2021

Clinical practice and preventive health guidelines available on anthem.com

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 our website at anthem.com/provider > Select Policies, Guidelines & Manuals under Provider Resources > scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.


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AdministrativeCommercialDecember 1, 2021

Professional system updates for 2022

As a reminder, we will continue to upgrade our claim editing software for professional services monthly throughout 2022, with most updates occurring quarterly. These upgrades may apply to same provider, provider group (tax identification number). They may also apply across providers and across claim types (professional/facility) and include, but are not limited to:
  • addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits such as:
    • ICD-10 laterality and Excludes1 notes
    • Add-on procedures (indicated by + sign)
    • Code book parenthetical statements and other directives about appropriate code use (e.g. “separate procedure”, “do not report”, “list separately in addition to”, etc...)
  • updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
  • updates to incidental, mutually exclusive, and unbundled (rebundle) edits
  • updates to assistant and co-surgeon eligibility in accordance with the policy
  • updates to edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

 

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AdministrativeCommercialDecember 1, 2021

Coordination of care

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral.  Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

 

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

 

We expect all health care practitioners to:

  1. Discuss with the patient the importance of communicating with other treating practitioners.
  2. Obtain a signed release from the patient and file a copy in the medical record.
  3. Document in the medical record if the patient refuses to sign a release.
  4. Document in the medical record if you request a consultation.
  5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
  6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
  • Diagnosis
  • Treatment plan
  • Referrals
  • Psychopharmacological medication (as applicable)

 

In an effort to facilitate coordination of care, Anthem has several tools available on our anthem.com/provider website for behavioral health and other medical practitioners including:

  • Coordination of Care Form
  • Coordination of Care Letter Template - Behavioral Health
  • Coordination of Care Letter Template - Medical

 

The following behavioral health forms, brochures, and screening tools for substance abuse and attention-deficit/hyperactivity disorder (ADHD) are also available on our anthem.com/provider website: 

  • Alcohol Use Assessment Brochure
  • Antidepressant Medication Management
  • Edinburgh Postnatal Depression Scale
  • Opioid Use Assessment Brochure
  • Substance Brief Intervention/Referral Tool (SBIRT)
  • Vanderbilt ADHD Diagnostic Parent Rating Scale

 

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AdministrativeCommercialDecember 1, 2021

Member rights and responsibilities

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield (Anthem) has adopted a member rights and responsibilities statement.

 

To read the member rights and responsibilities statement, visit the Policies, Guidelines and Manuals page of our provider website. Scroll down the page and select “Read about member rights.” Under the FAQ question titled “Laws and Rights that Protect You” you can find information about Anthem member rights and responsibilities.

 

Practitioners may access the FEP member portal at fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

 

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Digital SolutionsCommercialDecember 1, 2021

Reminder: EnrollSafe is available: electronic funds transfer enrollment portal for Anthem Blue Cross and Blue Shield providers

Effective November 1, 2021, EnrollSafe is available as the electronic funds transfer (EFT) enrollment portal for providers participating with Anthem Blue Cross and Blue Shield (Anthem) CAQH Enrollhub is no longer offering EFT enrollment to new users.

 

CAQH Enrollhub is the only CAQH tool decommissioned.  All other CAQH tools are not impacted.

 

EnrollSafe:  Secure and available 24-hours a day

 

If you need to change an EFT enrollment previously submitted through CAQH, or enroll a new bank account for EFT, visit the EnrollSafe portal at enrollsafe.payeehub.org and select “Register.”  Once you have completed registration, you’ll be directed through the EnrollSafe secure portal to the enrollment page.  There, you’ll provide the required information to receive direct payment deposits.  There is no fee to register for EFT via EnrollSafe.

 

Already enrolled in EFT through CAQH Enrollhub?

 

Please note if you’re already enrolled in EFT through CAQH Enrollhub, no action is needed.  Your EFT enrollment information is not changing as a result of the new enrollment hub.

 

If you ever have changes to make to your bank account, use EnrollSafe going forward to update your EFT bank account information.

We’re here to help – EFT and ERA registration and contact information

 

Type of transaction

How to register, update, or cancel

For registration related questions

To resolve issues after registration

EFT only

Use EnrollSafe

EnrollSafe help desk at

877-882-0384

 

Available Monday through Friday 9 a.m. to 8 p.m. ET, except public and/or bank holidays.

 

Email: Support@payeehub.org

EnrollSafe help desk at

877-882-0384

 

Available Monday through Friday 9 a.m. to 8 p.m. ET, except public and/or bank holidays.

 

Email:

Support@payeehub.org

ERA (835) only

Use Availity

Availity Support at

800-282-4548

Availity Support at

800-282-4548

 

NOTE:  Providers should allow up to 10 business days for ERA enrollment processing.

 

 

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Medical Policy & Clinical GuidelinesCommercialDecember 1, 2021

Updates to AIM Advanced Imaging Clinical Appropriateness Guideline (MAC)

Material adverse change (MAC)

 

Effective for dates of service on and after March 13, 2022, the following guideline updates will apply to the AIM Specialty Health® (AIM) Advanced Imaging Clinical Appropriateness Guideline. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services

 

Imaging of the brain

  • Acoustic neuroma – removed indication for CT brain and replaced with CT temporal bone
  • Meningioma – new guideline establishing follow-up intervals
  • Pituitary adenoma – removed allowance for CT following nondiagnostic MRI in macroadenoma
  • Tumor, not otherwise specified – added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

 

Imaging of the head and neck

  • Parathyroid adenoma – specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
  • Temporomandibular joint dysfunction – specified duration of required conservative management

 

Imaging of the heart

  • Coronary CT angiography – removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk

 

Imaging of the chest

  • Pneumonia – removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
  • Pulmonary nodule – aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT

 

Imaging of the abdomen and pelvis

  • Uterine leiomyomata – new requirement for US prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
  • Intussusception – removed as a standalone indication
  • Jaundice – added requirement for US prior to advanced imaging in pediatric patients
  • Sacroiliitis – defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
  • Azotemia – removed as a standalone indication
  • Hematuria – modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
  • Diffuse liver disease – new indication for multiparametric MRI for fibrosis and hemochromatosis

 

 

Oncologic imaging

  • National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin & non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
  • Cancer screening: new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
  • Breast cancer: clinical scenario clarifications for diagnostic breast MRI and PET/CT

 

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

  • Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • 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 and upcoming guidelines here.

 

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Medical Policy & Clinical GuidelinesCommercialDecember 1, 2021

Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guideline (MAC)

Material adverse change (MAC)

 

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® (AIM) Radiation Therapy and Proton Beam Therapy Clinical Appropriateness Guideline. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services

 

  • Removed ECOG status as definition for performance status throughout guidelines.

 

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

  • Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • 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 and upcoming guidelines here.

 

1443-1221-PN-GA

Medical Policy & Clinical GuidelinesCommercialDecember 1, 2021

Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines (MAC)

Material adverse change (MAC)

 

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® (AIM) Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

 

Diagnostic coronary angiography

  • Removed indications for asymptomatic patients (in alignment with the ISCHEMIA trial)
  • Facilitated coronary angiography with a view to intervention in non-culprit vessels following ST-segment elevation myocardial infarction (STEMI), (in alignment with the COMPLETE trial)
  • For patients undergoing preoperative evaluation for TAVR or other valve surgery, aligned criteria with the updated ACC/AHA Guideline for the management of patients with valvular heart disease

 

Percutaneous coronary intervention

  • Revised criteria such that, for some cohorts, only those patients with persistent unacceptable symptoms and moderate or severe stress test abnormalities can proceed to revascularization (in alignment with the ISCHEMIA trial)
  • For non-left main percutaneous coronary intervention (PCI), expanded use to non-culprit vessels in patients following ST-segment elevation myocardial infarction (STEMI), and restricted use to those with moderate or severe stress test abnormalities who have failed medical therapy
  • Left main PCI limited to situations where coronary artery bypass grafting (CABG) is contraindicated or refused (in alignment with NOBLE and EXCEL trials)
  • Clarified requirements for patients who have undergone CABG: at least 70% luminal narrowing qualifies as stenosis, symptomatic ventricular tachycardia is considered an ischemic symptom, and instant wave-free ratio fractional flow reserve (iFR) is considered in noninvasive testing
  • Removed requirement to calculate SYNTAX score for patients scheduled to undergo renal transplantation
  • For patients scheduled for percutaneous valvular procedures (e.g., transcatheter aortic valve replacement/implantation (TAVR/TAVI) or mitral valve repair), added clarification that PCI should only be attempted for complex triple vessel disease when CABG is not an option.

 

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

  • Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • 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 and upcoming guidelines here.

 

1442-1221-PN-GA

Medical Policy & Clinical GuidelinesCommercialDecember 1, 2021

Updates to AIM Specialty Health Musculoskeletal Interventional Pain Management Clinical Appropriateness Guideline (MAC)

Material adverse change (MAC)

 

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® (AIM) Musculoskeletal Interventional Pain Management Clinical Appropriateness Guideline. As part of the AIM guideline annual review process, the following updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

 

Epidural injection procedures (ESI) and diagnostic selective nerve root blocks (SNRB):

  • Allow more frequent ESI in newly diagnosed patients
  • Remove imaging requirement in certain circumstances
  • Require similar criteria as ESI for diagnostic SNRB
  • Add epidural abscess as a contraindication
  • Limit multilevel and combination diagnostic SNRB

Paravertebral facet injection/medial branch block (MBB)/neurolysis:

  • Limit indefinite use of diagnostic MBB
  • Add indication for diagnostic pars defect MBB
  • Expand exceptions allowed for intraarticular facet injections
  • Define MBB timing with respect to radiofrequency neurotomy, MBB limited to RFA candidacy
  • Limit open surgical neurolysis, and limited multiple spinal injections

Sacroiliac joint injections:

  • Limit indefinite use of diagnostic intraarticular injections
  • Disallow sacral lateral branch blocks
  • Disallow sacroiliac joint therapeutic injections in a previously fused joint

Spinal cord and nerve root stimulators:

  • Allow minimally invasive pain procedures to satisfy conservative management definition
  • Specify timing of mental health evaluation
  • Define indications for repeat stimulator trial

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

  • Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • 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 and upcoming guidelines here.

 

1441-1221-PN-GA

Reimbursement PoliciesCommercialDecember 1, 2021

New reimbursement policy update: Modifier 62: Co-Surgeon Services and Modifier 66: Surgical Teams (professional)

Beginning with dates of service on or after March 1, 2022, the Anthem Blue Cross and Blue Shield (Anthem) Co-Surgeon/Team Surgeon Services commercial reimbursement policy will be retired and replaced with the following reimbursement policies:

 

  • Modifier 62: Co-Surgeon Services – professional: Under this reimbursement policy, Anthem allows reimbursement of procedures eligible for co-surgeons when billed with modifier 62. Anthem follows the Centers for Medicare & Medicaid Services (CMS) Medicare Physician Fee Schedule (MPFS) Co-Surgery payment indicators and will allow services requiring a co-surgeon billed with CMS MPFS payment indicator ‘2’ (always) and will deny services billed with indicator ‘0’ (never), ‘1’ (sometimes) and ‘9’ (not applicable). Reimbursement for each surgeon is based on 63 percent of the applicable fee schedule or contracted/negotiated rate.

 

  • Modifier 66: Surgical Teams – professional: Under this reimbursement policy, Anthem allows the of procedures eligible for surgical teams when billed with modifier 66. Anthem follows the CMS MPFS Team Surgery payment indicators and will allow services requiring team surgery billed with CMS MPFS payment indicator ‘1’ (sometimes) and ‘2’ (always), and will deny services billed with the indicator ‘0’ (never) and ‘9’ (not applicable).

 

For more information about this policy, visit the Reimbursement Policy page at anthem.com/provider.

 

1480-1221-PN-GA

Reimbursement PoliciesCommercialDecember 1, 2021

RETRACTION: Inpatient Facility Transfers reimbursement policy (facility)

In the September 2021 edition of Provider News, we announced that a new commercial reimbursement policy titled Inpatient Facility Transfers (facility) would be effective for dates of service on or after December 1, 2021.  We have made a decision to retract this reimbursement policy.

 

1464-1221-PN-GA

Reimbursement PoliciesCommercialDecember 1, 2021

Reimbursement policy update: Virtual Visits (professional and facility)

Beginning with dates of service on or after January 1, 2022, the Anthem Blue Cross and Blue Shield (Anthem) Virtual Visits commercial reimbursement policy will be updated to add the following:
  • Place of service 10 (telehealth provided in patient’s home)
  • Place of service 02 (telehealth provided other than in patient’s home)

 

Services reported by a professional provider with a place of service 02 or 10 will be eligible for non-office place of service reimbursement.

 

These correct coding updates align with the telehealth place of service updates released by the Centers for Medicare & Medicaid Services (CMS).

 

Additionally, the Related Coding section of the policy is updated to clarify that for Q3014, the member must be physically present in the originating facility.

 

For more information about this policy, visit the Reimbursement Policy page at anthem.com/provider.

 

1462-1221-PN-GA

Reimbursement PoliciesCommercialDecember 1, 2021

Reimbursement policy update: Assistant at Surgery (Modifiers 80, 81, 82, AS) (Professional) (MAC)

Material adverse change (MAC)

 

Beginning with dates of service on or after March 1, 2022, the Assistant Surgeon Services commercial reimbursement policy will be renamed Assistant at Surgery (Modifier 80, 81, 82, AS).  This policy follows the Centers for Medicare & Medicaid Services (CMS) guidelines for the codes designated as ‘MPFS Assistant Surgery payment indicator ‘2’ “Always” requiring an assistant surgeon. Codes identified with MPFS Assistant Surgery payment indicators ‘0’, ‘1’, and ‘9’ are not allowed for reimbursement. Additionally, the Assistant Surgeon Coding list will be retired.   


For more information about this policy, visit the Reimbursement Policy page at anthem.com/provider.


1460-1220-PN-GA

Products & ProgramsCommercialDecember 1, 2021

Case Management Program

Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

 

Anthem Blue Cross and Blue Shield is available to offer assistance in these difficult moments with our Case Management Program.  Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers.  The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

 

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need.  Physicians can also refer by contacting us telephonically or through electronic means.  No issue is too big or too small.  We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

 

How do you contact us?

State

CM Email Address
(if available)

CM

Telephone #

CM

Business Hrs.

 

GA

GaLocalCaseManagement@choosehmc.com

800-353-0923

Monday - Friday- 8am – 7:00pm EST

 

 

         

NATIONAL

 

GA

CMNATIONALACT-ATL@anthem.com

1-866-202-8727

800-824-0581 (Transplant)

Mon - Friday 8am-9pm EST,

Saturday 9am-5:30pm EST     

Mon-Friday 8:30am-5pm EST (Transplant)

 

FEDERAL EMPLOYEE PROGRAM (FEP)

 

All states, except CA

FEP.Care.Coordination@anthem.com

1-800-711-2225

9am-5pm in members time zone

 

                         

 

1446-1220-PN-GA

 

Products & ProgramsCommercialDecember 1, 2021

Updated AIM musculoskeletal program site of care reviews delayed

In the August 2021 edition of Anthem’s Provider News, we announced an expansion to the AIM Specialty Health® (AIM) musculoskeletal program for medical necessity review of the requested site of service for certain joint and interventional pain procedures for Anthem fully-insured members. This program has been delayed. AIM will begin accepting prior authorization requests on December 13, 2021 for dates of service on January 1, 2022 and after.  

 

Medical necessity for musculoskeletal procedures are still required. All codes and clinical guidelines included in the musculoskeletal program can be found on the AIM MSK website.


1429-1221-PN-GA

PharmacyCommercialDecember 1, 2021

Pharmacy information available on anthem.com

Visit Pharmacy Information for Providers on 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 marketplace drug lists 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, 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 fepblue.org > Pharmacy Benefits.

 

1447-1220-PN-GA

PharmacyCommercialDecember 1, 2021

December 2021 specialty pharmacy updates (MAC)

Material adverse change (MAC)

 

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

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.

 

Please note that inclusion of National Drug Code (NDC) code on your claim 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 March 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

HCPCS or CPT Code(s)

Drug

*ING-CC-0018

J3490

J3590

C9399

Nexviazyme (avalglucosidase alfa-ngpt)

*ING-CC-0034

J1744

Sajazir (icatibant)

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

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

 

Quantity limit updates

 

Effective for dates of service on and after March 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

HCPCS or CPT Code(s)

Drug

*ING-CC-0018

J3490

J3590

C9399

Nexviazyme (avalglucosidase alfa-ngpt)

*ING-CC-0034

J1744

Sajazir (icatibant)

* Non-oncology use is managed by Anthem’s medical specialty drug review team.


 1440-1220-PN-GA

 

 

PharmacyCommercialDecember 1, 2021

Anthem Blue Cross and Blue Shield clinical criteria updates for specialty pharmacy are available

Effective for dates of service on and after March 1, 2022, the following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

 

Access the clinical criteria document information.

 

The Anthem Blue Cross and Blue Shield (Anthem) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Drugs used for the treatment of oncology will be managed by AIM Specialty Health® (AIM) (AIM), a separate company.

 

ING-CC-0012

Brineura (cerliponase alfa)

ING-CC-0021

Fabrazyme (agalsidase beta)

ING-CC-0099

Abraxane (paclitaxel, protein bound)

ING-CC-0100

Istodax (romidepsin)

ING-CC-0125

Opdivo (nivolumab)

ING-CC-0128

Tecentriq (atezolizumab)

 

1421-1221-PN-GA

State & FederalMedicare AdvantageDecember 1, 2021

Keep up with Medicare news

State & FederalMedicare AdvantageDecember 1, 2021

Somatus is your resource for kidney care management

Medicare Advantage

 

Somatus is your resource for kidney care management

 

We are pleased to announce a new no-cost care management program available for your Medicare Advantage covered patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD). This high-touch program, delivered by Somatus*, is designed to support and enhance your existing patient care by providing hands-on, one-on-one care management to eligible patients with kidney disease.

 

Somatus is the leading and largest provider of kidney care management services in the country. Through an innovative care-delivery model, Somatus surrounds patients with access to the full suite of support services and education needed to delay kidney disease progression and retain quality of life.

 

Somatus’ care management services are personalized to each participating member and may include:

  • A full care team comprised of a nurse, community health worker, pharmacist, dietitian, and social worker.
  • Ongoing in-home physical assessments, environmental assessments, face-to-face education, and health coaching to identify problems early and avoid potential hospitalizations and complications.
  • Comprehensive 1:1 care management of the patient’s kidney disease and co-morbidities, delivered in person (at home, clinic, or hospital) or via telephone.
  • Clinical and logistical assistance to help patients transfer safely from hospital to home, if needed.
  • Meal planning, appointment scheduling, transportation coordination, connection to local resources and community-based organizations, and more.

 

Anthem Blue Cross and Blue Shield will identify Medicare Advantage patients in your practice that qualify for and would benefit from Somatus’ kidney-care services, and we look forward to working with you to ensure these patients enroll and take part in this no-cost opportunity. A member of the Somatus team will be in touch to discuss your eligible patients and how you can help encourage their participation.

 

For more information about Somatus, visit somatus.com or, contact the Somatus Care Team at:

  • Phone: 855-851-8354, Monday through Friday, 9:00 a.m. to 9:00 p.m. ET
  • Email: care@somatus.com

 

ABSCRNU-0285-21

State & FederalMedicare AdvantageDecember 1, 2021

Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Medicare Advantage

 

Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

 

Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Updates by guideline:

Imaging of the Brain:
    • Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
    • Meningioma — new guideline establishing follow-up intervals
    • Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
    • Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features
Imaging of the Head and Neck:
  • Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
  • Temporomandibular joint dysfunction — specified duration of required conservative management
Imaging of the Heart:
  • Coronary CT angiographyremoved indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
Imaging of the Chest:
  • Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
  • Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
Imaging of the Abdomen and Pelvis:
  • Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
  • Intussusception — removed as a standalone indication
  • Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
  • Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
  • Azotemia — removed as a standalone indication
  • Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
  • Diffuse liver disease – new indication for multiparametric MRI for fibrosis and hemochromatosis
Oncologic Imaging:
  • National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and Non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
  • Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
  • Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM via:

  • AIM’s ProviderPortalSM directly at providerportal.com.
    • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
  • The Availity* Portal at availity.com.
  • Phone at 800-714-0040, Monday through Friday from 7 a.m. to 7 p.m. CT.

 

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

 

ABSCRNU-0281-21

State & FederalMedicare AdvantageDecember 1, 2021

Adjudicating claims for COVID-19 vaccines, their administration and COVID-19 monoclonal antibodies

Medicare Advantage

 

Adjudicating claims for COVID-19 vaccines, their administration and COVID-19 monoclonal antibodies

 

Beginning January 1, 2022, Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans

(MMPs) are responsible for adjudicating claims for COVID-19 vaccines and their administration and for

COVID-19 monoclonal antibodies and their administration. 

 

ABSCRNU-0286-21

State & FederalMedicare AdvantageDecember 1, 2021

2022 Medicare Advantage service area and benefit updates

Medicare Advantage

 

2022 Medicare Advantage service area and benefit updates

 

An overview of notable 2022 benefit changes and service area updates are now available. Please continue to check anthem.com/medicareprovider for the latest Medicare Advantage information.

 

ABSCRNU-0283-21

State & FederalMedicare AdvantageDecember 1, 2021

Policy Update: Drug Screen Testing

Medicare Advantage

 

Policy update: Drug Screen Testing

(Effective March 1, 2022)

 

Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override. 

 

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

 

ABSCRNU-0270-21

State & FederalMedicare AdvantageDecember 1, 2021

Non-payment remittance advice enhancements

Medicare Advantage

 

You can now search, review, and download a copy of the remittance advice from Availity.com* when there is not an associated payment. For remittance advice with payment, you can continue to search with the check or electronic funds transfer (EFT) number.

 

Images reflecting current check numbering:

 

Paper remittance

Electronic remittance advice (ERA/835)


What has changed?

  1. Non-payment number display in the Check Number and Check/EFT Number fields:
    • Prior to enhancement — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
    • Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

 

  1. Searching for non-payment remittance:
    • Prior to enhancement — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to search for a specific remittance because the same number (10 bytes (9999999999) was being used for every non-payment remittance.
    • Enhancement — When the unique ERA non-payment remittance number is applied, it can be entered in the check number field in Remit Inquirymaking it easier to find a specific remittance.

 

You will continue to receive remittances and payments as you always have. These enhancements will make it easier for you to find and reconcile non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

ABSCRNU-0260-21