 Provider News GeorgiaFebruary 2021 Anthem Provider News - GeorgiaEffective January 1, 2021, all NECA/IBEW Family Medical Care Plan members have new ID numbers. Please use the new number for services rendered as of January 1, 2021. FMCP has advised its membership to remember to share this new card/ID number with all their providers for all services obtained after the first of the year. After January 1, 2021, please contact Anthem Provider Services at 833-835-2714 for eligibility and benefit questions and call 855.343.4851 to request prior authorization.
Anthem Blue Cross and Blue Shield will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
In January we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.
In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:
- Medical Policies and Clinical Guidelines
- Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)
Steps to access the Authorization Lookup application through Availity Payer Spaces
Access to the tool does not require an Availity role assignment.
- Select Payer Spaces
- Select the Anthem Blue Cross and Blue Shield tile from the Payer Spaces menu
- Select the Applications tab
- Select the Authorization Rules Lookup tile
Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:
- Tax ID
- National Provider Identifier (NPI)
- Member ID and birth date
- Member’s Group number or Contract Code
(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)
Give this new tool a try and discover how much this will improve the efficiency of your authorization process.
Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal.
A new professional reimbursement policy titled Professional Anesthesia Services will be implemented beginning with dates of service on, or after May 1, 2021. The policy outlines reporting requirements for professional anesthesia services including time, modifiers, global services, anesthesia for oral surgery, qualifying circumstances and anesthesia for post-operative pain management.
For more information about this policy, visit the Reimbursement page on our anthem.com/provider website.
A new facility reimbursement policy titled Emergency Room Transfers will be implemented beginning with dates of service on, or after May 1, 2021. The policy allows reimbursement for one emergency room visit when a patient is transferred between facilities operating under the same agreement, have the same tax identification number (TIN), or is under common ownership. The transferring facility will not be eligible for separate reimbursement.
For more information about this policy, visit the Reimbursement page on our anthem.com/provider website.
A new facility reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services will be implemented beginning with dates of service on, or after May 1, 2021. Anthem Blue Cross and Blue Shield does not allow reimbursement for office evaluation and management services when reported on a CMS 1450 (UB-04) with revenue code 761 (treatment rooms). Modifiers will not override the edit.
For more information about this policy, visit the Reimbursement page on our anthem.com/provider website.
Effective with dates of service on and after April 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem will update its drug lists that support commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes by opening the attached PDF titled “Anthem Summary_of_Formulary_Changes_2.1.21.pdf.”
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.
Effective for dates of service on and after May 1, 2021, 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.
Anthem’s 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), a separate company.
- ING-CC-0003 Immunoglobulins
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0041 Complement Inhibitors
- ING-CC-0048 Spinraza (nusinersen)
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0063 Stelara (ustekinumab)
- ING-CC-0071 Entyvio (vedolizumab)
- ING-CC-0121 Gazyva (obinutuzumab)
- ING-CC-0174 Kesimpta (ofatumumab)
- ING-CC-0183 Sogroya (somapacitan-beco)
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/pharmacyinformation. 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.
Prior authorization updates
Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, 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.
To access the Clinical Criteria information please click here.
Anthem Blue Cross and Blue Shields’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0183
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J3590
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Sogroya
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*ING-CC-0001
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J0886
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Injection, epoetin alfa (Procrit/Epogen)
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*ING-CC-0019
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J3489
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Reclast, Zometa
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Quantity Limit Updates
Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Please note, 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.
To access the Clinical Criteria information please click here.
Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
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Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0019
|
J3489
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Reclast, Zometa
|
On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC (AMH Health). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020 Anthem and Clinical Criteria Web Posting September and October 2020 AMH Health. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
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