The Medical Policy and Technology Assessment Committee adopted the attached (see PDF) new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary.  Clinical Guidelines adopted by Anthem Blue Cross and Blue Shield and all the Medical Policies are available at the Anthem Blue Cross and Blue Shield website (Choose Providers > Medical Policies). Please note our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you don’t have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday–Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying medical policy or guideline of interest, your name and address to where information should be sent) to:

 

Anthem Blue Cross and Blue Shield

Attention: Prior Approval, Mail Code GAG009-0002

3350 Peachtree Road NE

Atlanta, GA 30326

NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.   

See attached PDF titled “GA Medical Policy and Clinical Guideline Updates 1/1/2019”.

 

The Medical Policy and Technology Assessment Committee adopted the following new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary.  Clinical Guidelines adopted by Anthem and all the Medical Policies are available at Anthem.com/provider under “see policies and guidelines”.  Please note that our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday through Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to:

 

Anthem Blue Cross and Blue Shield

Attention: Prior Approval, Mail Code GAG009-0002

3350 Peachtree Road NE

Atlanta, GA 30326

 

NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a Group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.   

Anthem is committed to investing in primary care, rewarding coordinated, patient-centered care, and promoting proactive chronic care management. In recognition of the time-intensive nature of this work, Anthem will reimburse chronic care management and advance care planning services for Commercial health plans effective for claims processed on or after February 23, 2019.

 

Chronic care management (CCM) is care rendered by a physician or non‐physician health care provider and their clinical staff, once per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only one practitioner can bill a CCM service per service period (month). Three CCM codes are included in this payment policy change:  99490, 99487and 99489.

 

Advance care planning (ACP) is a face-to-face service between a physician or other qualified health care professional and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time.  No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary. Two ACP codes are included in the payment policy change: 99497 and 99498

 

Anthem requires patient consent prior to CCM or ACP service(s) being provided. Please refer to the current Claims Requiring Additional Documentation policy for more information. 

 

For more information, review our Bundled Services and Supplies policy dated February 23, 2019 by visiting the Reimbursement Policies page at anthem.com/provider website. 

 

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, go to Customer Support, select your state, Download Forms and choose “Select Drug List.”  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.

Anthem continually monitors and updates the list of drugs not approved by the Food and Drug Administration (FDA), which are considered non-covered under prescription drug benefits. When drugs are added to this list, Anthem notifies impacted members that the drug is not FDA approved and will no longer be covered.

Effective December 1, 2018, these drugs were added to our list of drugs not approved by the FDA.

For new members just beginning an Anthem plan or not yet having used one of these non-FDA-approved drugs, coverage for these drugs ended December 1, 2018.

Existing members who had been identified as already using at least one of the drugs added to the list received a letter to let them know their drug(s) will no longer be covered after December 31, 2018. However, if the patient had a prior authorization for a drug on this list, coverage for that drug continued until the prior authorization expired on December 31, 2018.

Anthem is committed to offering efficient and streamlined solutions for submitting prior authorizations (PAs).  This helps reduce the administrative burden while improving the member experience for their patients.

 

Anthem’s Proactive PA process approves select drugs in real time, using an automated prior authorization (PA) process. Proactive PA uses integrated medical and pharmacy data to seamlessly approve medication prior authorization requests where diagnoses are required. Anthem’s prior authorization process helps to ensure clinically appropriate use of medications.

Providers can take advantage of the electronic prior authorization (ePA) submission process by logging in at covermymeds.com. Creating an account is FREE, and many prior authorizations are approved in real time. Read more about the ePA submission process in the previously published article titled “BCBSGa accepts electronic prior authorization requests for prescription medications online.”

Additionally, providers may be able to access real-time, patient-specific prescription drug benefits information through their electronic medical record (EMR) system. To learn more about this feature, review the article titled “Access patient-specific drug benefit information through EMR” that was published in the October 2018 edition of our provider newsletter.