 Provider News GeorgiaFebruary 1, 2023 February 2023 Anthem Provider News - GeorgiaThe Controlling High Blood Pressure (CBP) HEDIS® measure can be challenging as it not only requires proof of a blood pressure (BP) reading, but also that the patient’s blood pressure is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 140/90 mmHG.As we start a new year, it’s important that we have record of your patients’ blood pressure readings and that you continue to monitor patients with elevated readings. Tips when scheduling members to close CBP care gaps: - When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
- If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time as well as a reminder to arrive early to avoid a sense of rushing.
Tips for lower BP readings during the appointment: - Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their blood pressure at both the start and end of the appointment and document the lower reading.
- Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.
Getting credit for adequately controlled blood pressure readings: - Submit readings via Category II CPT® codes on claims.
Description | Code | Diastolic BP | CAT II: 3078F-3080F LOINC: 8462-4 | Diastolic 80 to 89 | CAT II: 3079F | Diastolic greater than/equal to 90 | CAT II: 3080F | Diastolic less than 80 | CAT II: 3078F | Systolic BP | CAT II: 3074F, 3075F, 3077F LOINC: 8480-6 | Systolic greater than/equal to 140 | CAT II: 3077F | Systolic less than 140 | CAT II: 3074F, 3075F |
- Ensure readings are carefully and appropriately documented within your electronic medical record system.
- If you have questions on how to submit readings, speak to your care or practice consultant.
- Also, be sure to adequately code patients who meet the exclusion criteria:
- Exclusions:
- Palliative care
- Enrolled in hospice
- Frailty and/or advanced illness
- Living in long-term care
- Optional exclusions:
- Dialysis (ESRD), kidney transplant, nephrectomy
- Female members with a diagnosis of pregnancy
- Non-acute inpatient admissions
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). GABCBS-CM-012290-22-CPN10532 The Consolidated Appropriations Act, implemented in 2021, contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. We ask that you to review your online provider directory information on a regular basis to ensure it is correct. To access your information, go here. Then, under Provider Overview, select 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 form, we will send you an email acknowledging receipt of your request. MULTI-BCBS-CM-016525-22-CPN16491 The Department of Health and Human Services (HHS) Notice of Benefit and Payment Parameters for 2023 Final Rule for Marketplace health plans has a Network Adequacy provision regarding telehealth services. As of January 2023, HHS requires health plans to identify and report the in-network providers who offer telehealth services. As a participating provider with Anthem Blue Cross and Blue Shield, if you provide telehealth services, please let us know by submitting your information to us via the online Provider Maintenance Form, which can be found at anthem.com or through Availity Essentials.* We will add a telehealth indicator to your online provider directory profile so our members know you offer this service. If you have questions about submitting your information, please contact Provider Services.
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. MULTI-BCBS-CM-017258-23-CPN17179 We are committed to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year. Stay tuned for more updates. GABCBS-CRCM-016118-22-CPN15788 The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is: - We’ll receive the documents needed faster than through the mail.
- Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
- Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
- More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.
However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays: - Valid claim number
or
- Valid member ID with prefix and correct dates of service
or
- Valid member ID with prefix and billed charges
For a clinical appeal, ensure these elements are included: - Valid claim number
or
- Valid member ID with prefix and correct dates of service
or
- Valid member ID with prefix) and billed charges
or
- Member name, member date of birth, and correct dates of service
or
- Member name, member date of birth, authorization, or reference number
This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission. The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission. To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation. For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal. If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation. For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow. * Availity, LLC is an independent company providing administrative support services on behalf of health plan. MULTI-BCBS-CM-016609-22-CPN16477 To view the 2023 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to www.fepblue.org > select Tools & Resources > Brochure & Resources. Here, you will find the Service Benefit plan brochure, benefit plan summaries, and Quick Reference Guides on information for year 2023. If you have questions, please contact FEP Customer Service at: CO – 800-852-5957 CT – 800-438-5356 GA – 800-282-2473 IN – 800-382-5520 KY – 800-456-3967 ME – 800-722-0203 MO – 800-392-8043 NV – 800-727-4060 NH – 800-852-3316 NY – 800-522-5566 OH – 800-451-7602 VA – 800-552-6989 WI – 800-242-9635
Material adverse change Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’s medical specialty drug review team. 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. As of the effective date below, you may be required to submit a prior authorization for your patients’ continued use of these medications. Including the National Drug Code (NDC) code on your claim may help expedite claim processing for drugs billed with a Not Otherwise Classified (NOC) code. Reminder: Clinical Criteria name change In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged. Prior authorization updates Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0226*+ | Elahere (mirvetuximab) | J3590, J9999 | CC-0223*+ | Imjudo (tremelimumab-actl) | J3490, J3590, J9999 | CC-0224*+ | Pedmark (sodium thiosulfate injection) | J3490, J9999 | CC-0222*+ | Tecvayli (teclistamab-cqyv) | J3490, J3590, J9999 | CC-0225+ | Tzield (teplizumab-mzwv) | J3490, J3590 | CC-0107*+ | Vegzelma (bevacizumab-adcd) | J3590, J9999 | CC-0072+ | Vegzelma (bevacizumab-adcd) | J3590 |
* Oncology use is managed by AIM. + The applicable Clinical Criteria is attached to this article in PDF format. Note: 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 May 1, 2023, 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 CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent. Clinical Criteria | Status | Drug | HCPCS or CPT code(s) | CC-0107*+ | Non-preferred | Alymsys | C9142, J3490, J3590, J9999 | CC-0107* | Non-preferred | Vegzelma | J3590, J9999 | CC-0107* | Non-preferred | Zirabev | Q5118 | CC-0107* | Preferred | Avastin | J9035 | CC-0107* | Preferred | Mvasi | Q5107 |
* Oncology use is managed by AIM. + The applicable Clinical Criteria is attached to this article in PDF format. Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status. Quantity limit updates Effective for dates of service on and after May 1, 2023, 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) | CC-0225+ | Tzield (teplizumab-mzwv) | J3490, J3590 | CC-0072+ | Vegzelma (bevacizumab-adcd) | J3590 |
+ The applicable Clinical Criteria is attached to this article in PDF format. * AIM Specialty Health is an independent company providing some utilization review services on behalf of the health plan. MULTI-BCBS-CM-016921-23 Material adverse change
Effective for dates of service on and after April 1, 2023, the following code updates will apply to the AIM Specialty Health®* Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. Percutaneous coronary intervention: CPT® code | Description | C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | C9601 | Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | C9603 | Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel | C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) | C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel | C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) |
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 Essentials at availity.com
If you have 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. * AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. MULTI-BCBS-CR-013612-22-CPN12754 In June 2022, myNEXUS* announced that it joined the Carelon family of companies. Carelon* is a new healthcare services brand dedicated to solving the industry's most complex challenges. As part of this shift, myNEXUS will begin operating under a new name, Carelon Post Acute Solutions, on March 1, 2023. In March, any documents that mention myNEXUS, such as provider forms or the myNEXUSwebsite (https://www.mynexuscare.com), will begin adopting the new Carelon Post Acute Solutions name. This is a name change only and does not impact the services myNEXUS offers or the way myNEXUS works with providers. Learn more about Carelon and myNEXUS by visiting:
https://www.carelon.com/about-us/businesses/mynexus * myNEXUS/Carelon is an independent company providing post acute care services on behalf of the health plan. MULTI-BCBS-CR-016950-22-CPN16447 |