 Provider News GeorgiaFebruary 1, 2019 February 2019 Anthem Provider Newsletter - GeorgiaAs previously communicated, we will continue hosting in-person Town Hall style provider orientation meetings throughout 2019. 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:
Topics will include:
- Commercial Risk Adjustment
- Network updates
- Availity
- State Health Benefit Plan (SHBP)
- AIM Specialty Health® (AIM) programs
- Exchanges
- Medicare
- Provider Experience
- Provider Services contacts, general information and updates
February 12, 2019 – Gainesville
The Northeast Georgia History Center
322 Academy Street NE
Gainesville, GA. 30501
11:30 a.m.–1:30 p.m., lunch will be provided.
Please R.S.V.P by Wednesday, February 6th to RSVPBlue@anthem.com. ** Seating is limited, please only allow two from your office to attend. Be sure to Include the name of the facility or practice, and the names and e-mail addresses.
Thursday, March 14, 2019 – Albany
Phoebe Northwest
2336 Dawson Road, Albany, GA
Conference Rooms A, B and C
11:30-1:30 p.m., lunch will be provided.
Please R.S.V.P. by Wednesday, March 6th to RSVPBlue@anthem.com and include the name of the facility or practice, and the names and e-mail addresses.
April 9, 2019 – Atlanta
Emory North Decatur
2701 North Decatur Road
Decatur, GA. 30030
9:00 a.m.–10:30 a.m., breakfast will be provided.
The Theatre is on the ground floor of the main hospital. Take the A elevators to the ground floor, turn left and follow the signs for the Theatre/Auditorium.
Please R.S.V.P. by Wednesday, April 3rd to RSVPBlue@anthem.com and include the name of the facility or practice, and the names and e-mail addresses
May 16, 2019 – Columbus
Anthem 6087 Technology Parkway
Midland, GA 31820
11:30 – 1:30 p.m., lunch will be provided.
Please R.S.V.P. by Friday, May 11th to RSVPBlue@anthem.com ** Seating is limited, only allow two from your office to attend. Be sure to Include the name of the facility or practice, and the names and e-mail addresses.
Additional Provider Town Hall events will be held in the following Georgia locations:
- Athens
- Augusta
- Macon
- Rome
- Savannah
Dates to be determined. 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 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 Anthem Provider Maintenance Form located on the Provider Forms page of our anthem.com/provider website. Thank you for your help and continued efforts to keep our records up to date. Anthem conducts an annual satisfaction survey of our Member’s behavioral health outpatient service experience. The random survey is conducted based on receipt of claims. We have recently reviewed the 2018 survey experience results and wanted to share highlights with our network of behavioral health providers. The survey inquires about the member’s satisfaction with timeliness of treatment, practitioner service/attitude and office environment, care coordination (among the member’s various providers), prescriptions/medication management process (if applicable), financial and billing process, and their perceived clinical improvement. Our member is also asked to give an overall rating of the experience. The 2018 overall practitioner rating was 86% in Georgia based on the survey results.
We were pleased to see overall improvement in the survey results. In particular, two areas of focus over the last year, access and coordination of care. Members responding to the survey, indicated that obtaining an appointment was fairly easy and many respondents indicated that care was being coordinated among their providers, including medical. Care coordination and collaboration, particularly medical-behavioral integration, is a key focus at Anthem. We also encourage ongoing understanding of an individual’s cultural, spiritual and religious beliefs while in treatment.
While we are pleased with our member’s experience with our participating provider network and thank you for your network participation and the services you provide, we’d like to remind you of two key areas to maintain and improve satisfaction:
- Member’s Access to Behavioral Health Care: As a participating provider please be reminded of Anthem’s expectation, based on NCQA definitions, of access to behavioral healthcare to help ensure our members have prompt access to behavioral health care:
- Non-life threatening emergency needs: must be seen, or have appropriate coverage directing the member, within 6 hours. When the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
- Urgent needs: must be seen, or have appropriate coverage directing the member, within 48 hours. Urgent calls concern members whose ability to contract 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. Urgent needs have the potential to escalate into an emergency without clinical intervention.
- Routine office visit: must be within 10 business days. Routine calls concern members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
We use several methods to monitor adherence to these standards. Monitoring is accomplished by a) assessing the availability of appointments via phone calls and surveys by our staff or designated vendor to the provider’s office; b) analysis of member complaint data and c) analysis of member satisfaction. Providers are expected to make best efforts to meet these access standards for all members. Anthem continues to look at gaps, barriers and alternative options to improve access to behavioral healthcare including tele-health services.
- Members held harmless: As a participating provider in Anthem’s behavioral health provider network, a participating provider shall look solely to Anthem for compensation for covered services and under no circumstances shall render a bill or charge to any member except for applicable co-payments, deductibles and coinsurance and for services that are not medically necessary or are otherwise not covered, provided that the Provider obtains the consent of the Member before providing such service. We recommend that consent be in writing and dated, in order to protect our members and providers from disputes.
In addition, Anthem also reminds our participating providers that Anthem members must be advised of missed or cancelled appointment policies at the onset of treatment. We also recommend that the advisement be acknowledged by the member in writing, and that acknowledgement is dated.
Thank you again for the services that you provide to our members. One of the measures we report on is the Controlling High Blood Pressure (CBP) measure. This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).
What’s new for 2019?
- The Controlling High Blood Pressure (CBP) measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
- If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
- Compliant BP is defined as <140/90 mm Hg for all members.
- Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the Provider can be utilized for the measure.
What do we need from you?
We need the last 2 office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018 please send that documentation as well.
Common chart deficiencies:
- Recheck elevated blood pressures readings and document all BP readings in the medical record.
For more information on HEDIS, visit the Quality Improvement and Standards page on our anthem.com/provider website under the Health & Wellness tab.
Thank you for your continued cooperation and support of HEDIS.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Centauri Health Solutions is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers, and ask that you respond to the requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe. Centauri Health will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary). We ask that you please promptly comply within five (5) business days of the record requests. If you have any questions, please contact Catherine Carmichael with Blue Cross Blue Shield Federal Employee Program at (202) 942-1173 or Carol Oravec with Centauri at (440)793-7727. As a reminder, physicians are required to refer to in-network laboratories. Laboratory Corporation of America (LabCorp) is one of many labs participating in the PPO network. For a complete list of PPO labs see the “Find a Doctor” tool at anthem.com.
LabCorp is the exclusive national clinical reference laboratory provider for Anthem HMO, Open Access POS and Pathways members. For these members, this means referring to LabCorp. By doing so, members are assured of having the highest benefit level and minimum out-of-pocket expense.
Laboratory specimens can be collected in the office with LabCorp courier pick-up available throughout Georgia. Members may also bring a LabCorp requisition form completed by their physician, to any of the over one-hundred LabCorp Patient Service Center locations throughout Georgia. To find out about LabCorp Patient Service Center locations, go to anthem.com.
If you have questions about LabCorp services, need to set up a LabCorp account, order supplies or schedule a pick-up, please call LabCorp at 800-762-0890.
If you have questions about our provider network or coverage for your patients, please contact your Anthem network consultant. Beginning in May 2019, Anthem will enhance its’ claims editing systems to include outpatient facility editing.
These edits will:
- help ensure correct coding and billing practices are being followed
- help ensure compliance with industry standards such as American Medical Association (AMA), National Uniform Billing Committee (NUBC), and national specialty and academy guidelines
- reinforce compliance with standard code edits and rules (i.e., CPT, HCPCS, ICD-10, NUBC)
Preapproval changes are listed in the attached PDF. 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:
See attached PDF titled “GA Preapproval List Change Notification 2.1.2019”. Beginning with dates of service on or after May 1, 2019, Anthem is updating our Injectable Substances with Related Injection Services reimbursement policy. The update will reflect that when a claim for an injection service is submitted without the applicable Healthcare Common Procedure Coding System (HCPCS Level II) drug or injectable substance code for the injected drug or substance, the code for the injection service will not be eligible for reimbursement.
Additionally, when submitting a claim for an aspiration service, with or without an injection, be sure to include code J3590 (unclassified biologics) with a zero charge to indicate the biologic contents of the syringe after aspiration, or the service will not be eligible for reimbursement.
For additional information, review our updated policy dated May 1, 2019 by visiting the Reimbursement Policy page at anthem.com/provider.
To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM coding guidelines, when selecting the most appropriate diagnosis for patient encounters. Remember ICD-10-CM has two different types of excludes notes and each type has a different definition. In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes. An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section.
Beginning with dates of service on or after May 1, 2019, Anthem is updating the facility Body Mass Index (BMI) Reimbursement Policy. Reimbursement will be based on a review of all comorbidities, diagnosis codes reported, and the facility specific reimbursement methodology for Body Mass Index (BMI) diagnosis codes reported as a secondary clinical condition along with other criteria set forth in our policy.
For additional information, please review our updated policy dated May 1, 2019 by visiting the Reimbursement Policy page at anthem.com/provider. 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 anthem.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, scroll down to “Select Drug Lists.” 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.
FEP Pharmacy updates and other pharmacy related information may be accessed by clicking “Pharmacy Benefits” at fepblue.org.
AllianceRX Walgreens Prime is the specialty pharmacy program for the Federal Employee Program. You can view the 2018 Specialty Drug List or call us at 1-888-346-3731 for more information. The following clinical criteria will be effective May 1, 2019.
Erythropoiesis Stimulating Agents ING-CC-0001
Clinical criteria ING-CC-0001 addresses the use of recombinant erythropoietin products, also known as erythropoiesis stimulating agents (ESAs), for the treatment of severe anemia in chronic kidney disease (CKD), HIV, cancer, surgery, and other conditions.
Effective for dates of service on and after May 1, 2019, the use of Procrit®, Epogen®, and Retacrit™ for the treatment of severe anemia in hepatitis C, chronic inflammatory disease, and bone marrow transplant are considered not medically necessary.
H.P. Acthar Gel® (repository corticotropin injection) ING-CC-0004
Clinical criteria ING-CC-0004 addresses the use of repository corticotropin injection for the treatment of infantile spasms (West syndrome) and adults with a corticosteroid-responsive condition, including but not limited to acute exacerbations of multiple sclerosis.
Effective for dates of service on and after May 1, 2019, repository corticotropin injections for the treatment of conditions other than infantile spasms (West syndrome) are considered not medically necessary.
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists ING-CC-0072
Clinical criteria ING-CC-0072 addresses the use of intravitreal vascular endothelial growth factor (VEGF) antagonists for the treatment of diabetic retinopathy and other retinal disorders associated with neovascularization.
Effective for dates of service on and after May 1, 2019, the use of Eylea® for the treatment of radiation retinopathy is considered not medically necessary.
To access the clinical criteria information please click here. The following clinical criteria will be effective May 1, 2019.
Colony Stimulating Factor Agents ING-CC-0002
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Additional information regarding biosimilar drugs can be found by viewing the attached reference document, “Biosimilar Drugs – What are they?”
Access the clinical criteria information here.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code
|
NDC Code
|
|
ING-CC-0002
|
Preferred Agent
|
Zarxio®
|
Q5101
|
61314-0304-01
61314-0304-10
61314-0312-01
61314-0312-10
61314-0318-01
61314-0318-10
61314-0326-01
61314-0326-10
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Neupogen®
|
J1442
|
55513-0530-01
55513-0530-10
55513-0546-01
55513-0546-10
55513-0924-01
55513-0924-10
55513-0924-91
55513-0209-01
55513-0209-10
55513-0209-91
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Granix®
|
J1447
|
63459-0910-11
63459-0910-12
63459-0910-15
63459-0910-17
63459-0910-36
63459-0912-11
63459-0912-12
63459-0912-15
63459-0912-17
63459-0912-36
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Nivestym™
|
Q5110
|
00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
|
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new clinical criteria or current clinical guideline will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
The following clinical criteria will be effective May 1, 2019.
|
Clinical Criteria/Guideline
|
HCPCS or CPT Code
|
NDC Code
|
Drug
|
|
CG-DRUG-63
|
J3490
|
68152-0112-01
68152-0114-01
|
Khapzory™
|
|
ING-CC-0002
|
Q5110
|
00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
|
Nivestym™
|
|
ING-CC-0002
|
J3490
|
68152-0112-01
68152-0114-01
|
Udenyca™
|
|
ING-CC-0003
|
J1599
|
68982-0820-01
68982-0820-02
68982-0820-03
68982-0820-04
68982-0820-05
68982-0820-06
68982-0820-81
68982-0820-82
68982-0820-83
68982-0820-84
68982-0820-85
68982-0820-86
|
Panzyga®
|
|
ING-CC-0034
|
J3590
|
47783-0644-01
|
Takhzyro®
|
|
ING-CC-0062
|
J3590
|
61314-0871-02
61314-0871-06
61314-0876-02
|
Hyrimoz™
|
|
ING-CC-0062
|
Q5109
|
00069-0811-01
|
Ixifi™
|
|
ING-CC-0065
|
J7192
|
00026-3942-25
00026-3944-25
00026-3946-25
00026-3948-25
00026-4942-01
00026-4944-01
00026-4946-01
00026-4948-01
|
Jivi®
|
|
ING-CC-0074
|
J8655
|
69639-0102-01
|
Akynzeo®
|
|
ING-CC-0077
|
C9399
J3590
|
68135-0058-90
68135-0673-40
68135-0673-45
68135-0756-20
|
Palynziq™
|
|
ING-CC-0081
|
J0584
|
69794-0102-01
69794-0203-01
69794-0304-01
|
Crysvita®
|
|
ING-CC-0082
|
C9399
J3490
|
71336-1000-01
|
Onpattro™
|
To access the clinical criteria information click here. Effective January 1, 2019, the City of Atlanta began offering Anthem Blue Cross and Blue Shield Medicare Advantage plan. Retirees with Medicare Parts A and B are eligible to enroll in the Anthem Medicare Preferred (PPO) plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. In addition, City of Atlanta retirees will pay the same cost share for both in-network and out-of-network services.
The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers, and covers additional benefits such as an annual routine physical exam, hearing and vision benefits, LiveHealth Online and SilverSneakers®, which are not covered by Medicare.
The prefix on the City of Atlanta member ID cards will be YGZ. The cards will also show the City of Atlanta logo and National Access Plus icon.
Providers may submit claims electronically using the electronic payer ID for the Blue Cross Blue Shield plan in their state or submit a UB-04 or CMS-1500 form to the Blue Cross Blue Shield plan in their state. Claims should not be filed with Original Medicare. Contracted and noncontracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about City of Atlanta member benefits or coverage.
Detailed prior authorization requirements also are available to contracted providers by accessing the provider self-service tool at availity.com. Effective for dates of service beginning January 1, 2019, the following Medicare Part B devices are preferred to support cost-effective benefits. During precertification initiation or renewal, providers requesting a nonpreferred device will be encouraged to switch to a preferred product. The preferred and nonpreferred products are listed below.
|
Preferred devices
|
Nonpreferred devices
|
|
Euflexxa® (J7323)
Hyalgan®/Supartz®/Visco-3® (J7321)
Durolane® (J7318)
|
Gel-One® (J7326)
Gelsyn-3® (J7328)
Genvisc 850® (J7320)
Hymovis® (J7322)
MonoviscTM (J7327)
Orthovisc® (J7324)
Synvisc® or Synvisc-One® (J7325)
TriviscTM (J7329)
|
|
75557MUSENMUB 12/20/18 Refractions and routine eye exams are not covered under medical insurance for Anthem members. These benefits may be available through the member’s supplemental insurance. These services must be billed to the supplemental vendor. Check your patient’s Anthem ID card for the name of the vendor.
Additional information, including billing modifiers and documentation requirements, will be available at anthem.com/medicareprovider under Important Medicare Advantage Updates. AIM Specialty Health® groups CPT codes on authorizations so they can be reviewed together to support a procedure or therapy. Grouped codes are used for radiology, cardiology, and sleep and radiation therapy programs. The groupings can be found at aimspecialtyhealth.com/ClinicalGuidelines.html by selecting the appropriate solution and then the exam or therapy being performed. Additional information is available at anthem.com/medicareprovider under Important Medicare Advantage Updates. Anthem is required to follow all clinical and reimbursement policies established by Original Medicare in the processing of claims and determining benefits. Anthem follows all Original Medicare local coverage determinations, national coverage determinations, Medicare rulings, code editing logic and the Social Security Act.
Anthem may offer additional benefits that are not covered under Original Medicare. Certain benefits are only covered when provided by a vendor selected by Anthem. More information can be found at anthem.com/medicareprovider. You may also contact Provider Services at the phone number on the back of the member ID card. |