Provider News GeorgiaJuly 2021 Anthem Provider News - Georgia
Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving Star ratings.
Program objectives:
- Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas including telehealth, pharmacy measures, chronic disease monitoring, cancer screenings, documentation and more.
- Apply the knowledge you gain from the webinars to improve your organization’s quality.
Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.
REGISTER HERE for our upcoming clinical quality webinars!
Many members have both primary and secondary insurance policies, and it’s important to know which policy is primary. We want to make it as easy as possible for you to find out so you can avoid claim denials for not filing the secondary claim within the timely filing guidelines.
Before the member arrives for their appointment, check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto Availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for their appointment. After providing services, submit the member’s claim as usual – you can use Availity for that, too, through the Claims & Payments app.
If we are the secondary payer, we will need the explanation of benefits (EOB) from the primary carrier along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.
When a claim is submitted to us as the primary payer, and we are the secondary payer, our claim system will deny the claim because we don’t have the EOB. This can cause a delay in receipt of your payment and can even cause you to miss the timely filing guideline.
We want you to have of the information you need to know the very best way to file your claims. For more information about filing claims, visit Anthem.com/provider/claims-submissions. For help using Availity, log onto Availity.com and select the Help & Training tab.
In a recent study published by Pediatrics1, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.
The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.
The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.
The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.
- When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
- When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
- Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.
HEDIS® measure WCC looks at the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:
- Body mass index (BMI) percentile (percentage, not value)
- Counseling for nutrition
- Counseling for physical activity
Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.
Code services correctly to measure success
These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:
Description
|
CPT®
|
ICD-10-CM
|
HCPCS
|
BMI percentile
|
|
Z68.51-Z68.54
|
|
Counseling for nutrition
|
97802, 97803,
97804
|
Z71.3
|
G0270, G0271, G0447, S9449,
S9452, S9470
|
Counseling for physical activity
|
|
Z02.5, Z71.82
|
G0447, S9451
|
Codes to identify outpatient visits: CPT — 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483 HCPCS — G0402, G0438, G0439, G0463, T1015
|
|
ATTACHMENTS (available on web): 1232 image.jpg (jpg - 0.12mb) It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier! Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.
Self-testing: measurable difference when correct coding is reflected
This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it. Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.
Value set ID and subgroup
|
Code
|
Description
|
INR HOME MONITORING
|
CPT CODE 93792
|
Patient/caregiver training for initiation of home INR monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results.
|
INR HOME MONITORING
|
CPT CODE 93793
|
Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab INR test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.
|
INR HOME MONITORING
|
HCPCS CODE G0248
|
Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results.
|
INR HOME MONITORING
|
HCPCS CODE G0249
|
Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include four tests.
|
INR HOME MONITORING
|
HCPCS CODE G0250
|
Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include four tests.
|
INR clinical quality measure:
The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.
Clinical Quality Measure
|
Required documentation
|
CPT, HCPCS, LOINC and CPT Performance Codes
|
Provider Specialty
|
INR Monitoring for Individuals on Warfarin*
|
Adults 18 years of age and older who have had at least one 56- day interval of warfarin therapy and received at least one INR monitoring test during each 56-day interval with active warfarin therapy in the measurement year. Excludes patients who are monitoring INR at home during the treatment period
|
CPT 85610 - Prothrombin time LOINC 34714-6 INR blood by coagulation assay 6301-6 INR in platelet poor plasma by coagulation assay 38875-1 INR in platelet poor plasma or blood by coagulation assay 46418-0 INR in capillary blood by coagulation assay 52129-4 INR in platelet poor plasma by coagulation - post heparin adsorption Excludes: G0248 - demonstrate use home INR monitoring G0249 - provide test materials and equipment for home INR monitoring G0250 - physician INR test review interpretation and management
|
No provider type restrictions
|
Locating a case using Interactive Care Reviewer (ICR), the Anthem Blue Cross and Blue Shield (Anthem) digital authorization tool just got easier. We added the ICR Case Search tab within the tool so you can find cases submitted through ICR. Cases submitted through both ICR and other sources can still be located using the other search options: member, date range, reference/authorization request number or discharge date.
The steps to access ICR through the Availity portal have not changed. You are required to have the Authorization & Referral Request role or the Authorization & Referral Inquiry role. Your organization’s
Availity administrator can assign these roles.
- Log onto Availity’s home page with your unique user ID and password
- Select Patient Registration
- Select Authorizations & Referrals
- Select Authorization Inquiry
- Choose the Payer and Organization
- Accept the ICR Disclaimer
- Select Check Case Status from the ICR navigation bar
Here is what’s new:
The ICR Inquiry dashboard displays the new ICR Case Search tab. This new option is currently available for users who have the Authorization & Referral Request role. Users with the Authorization & Referral Inquiry role will be able to access the ICR Case Search tab in mid-July. Until then, the additional search options are available.
To locate a case submitted through ICR, select the ICR Case Search tab then choose the criteria to complete your search.
You can use the additional search options to find cases requested by and associated with your organization that were submitted through both ICR and other sources.
Use the additional search options to find cases through both ICR and other sources.
Register for our monthly new user ICR webinar to learn about basic navigation and features: ICR webinar registration
You can also visit the Custom Learning Center located on Availity Payer Spaces to access ICR navigation demonstrations and reference guides.
ATTACHMENTS (available on web): 1233 image.jpg (jpg - 0.21mb) Anthem Blue Cross and Blue Shield (Anthem) uses Availity as its exclusive partner for managing all electronic data interchange (EDI) transactions.
When your organizations claims are submitted either by your clearinghouse/vendor or submitted directly using practice management software, it’s important to review and utilize all responses to understand where your claims are in the adjudication process and if any action is required.
Below is a summary of the process for electronic files, and the response reports that are returned by Availity:
Electronic file is submitted to Availity
- Availity acknowledges receipt of file and validates for X12 format in a series of responses.
- The series of initial responses indicate whether an electronic file was successfully received in correct format and accepted by Availity.
- If errors occur, the impacted file will require resubmission to Availity.
- If your organization uses a clearinghouse/vendor, they are responsible for reviewing these response files.
HIPAA and business validation
- Electronic Batch Report (EBR) – This response acknowledges accepted claims and identifies claims with a HIPAA and business edits prior to routing for adjudication.
- Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice. (Edit examples include - Invalid subscriber ID for the date of service and invalid billing and coding per industry standards)
- Clearinghouse/vendors may provide their own version of this report to your organization.
Availity routes claims to payer Anthem
- Delayed Payer Report (DPR) – This response file contains an additional level of editing by the membership adjudication system.
- Currently this response only returns for the Medicare/ Medicaid lines of business.
- The commercial lines will return this response in the future, look for forthcoming communications with the details.
- Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice.
- Clearinghouses/vendors may provide their own version of this report to your organization.
If you have further questions on the response reports, please contact Availity at 800-282-4548.
AIM Speciality Health®
AIM Specialty Health®, a separate company, is a nationally recognized leader delivering specialty benefits management on behalf of Anthem for certain health plan members. Determine if prior authorization is needed for a Georgia Anthem member by visiting the “Medical Policy and Clinical UM Guidelines” page on our provider website or by calling the prior authorization phone number printed on the back of the member’s ID card. To submit your request for any of the services below, contact AIM online via AIM’s website at aimspecialtyhealth.com/goweb. From the drop-down menu, select GA. You may also call AIM toll-free at 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET
AIM provides benefits management for the programs listed below:
- Imaging level of care
- Genetic testing
- Diagnostic imaging management
- Cardiovascular services
- Radiation therapy services
- Rehabilitative services
- Outpatient sleep testing and therapy services
- Cancer care quality program
- Musculoskeletal (for fully insured)
- Upper gastrointestinal endoscopy in adults, and site of care for certain surgical serivces
For more details on these programs, please visit the AIM website. By clicking on the previous links, you will be directed to sites created and/or maintained by another, separate entity (“external site”). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the external sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the external sites. The information contained on the external sites should not be interpreted as medical advice or treatment provided by us.
Eligibility and benefits
Eligibility and benefits can be verified on anthem.com/provider or by calling the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. Except in the case of an emergency, failure to obtain preapproval prior to rendering the designated services listed below will result in denial of reimbursement.
Add to preapproval
|
GENE.00057
Gene Expression Profiling for Idiopathic Pulmonary Fibrosis
|
81554
|
Added 10/1/2021
|
LAB.00041
Machine Learning Derived Probability Score for Rapid Kidney Function Decline
|
0105U
|
Added 10/1/2021
|
MED.00137
Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion
|
0615T
|
Added 10/1/2021
|
MED.00004
Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
|
0658T
|
Added 10/1/2021
|
TRANS.00025
Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
|
0055U, 0087U, 0118U, 81479, 81599
|
Added 10/1/2021
|
The Medical Policy and Technology Assessment Committee (MPTAC) adopted the attached 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 on the Anthem provider website. 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 Georgia if included on the Georgia 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 MPTAC but not included in the Georgia 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.
Open the attached document titled “GA medical policy and clinical guideline updates 7.1.2021” to view the new and/or revised medical policies and clinical guidelines adopted by the MPTAC.
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit fepblue.org > policies & guidelines.
Beginning with dates of service on or after October 1, 2021, Anthem Blue Cross and Blue Shield’s (Anthem’s) current documentation and reporting guidelines for consultations policy will be renamed “Consultations.” This policy aligns with CMS guidance and does not allow reimbursement for inpatient (99251-99255) or outpatient (99241-99245) consultation codes, and requires providers to bill the appropriate office visit Evaluation and Management (E/M) code for consultation services.
For more information about this policy, visit the Reimbursement page on our anthem.com/provider website.
Beginning with dates of service on or after October 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will implement a new reimbursement policy titled Non-Patient Laboratory Services. Anthem does not allow reimbursement for non-patient laboratory services when reported on a UB-04 with bill type 014X unless provider, state, federal or CMS and/or requirements indicate otherwise.
For more information about this policy, visit the Reimbursement page on our anthem.com/provider website.
As previously communicated in the Anthem Blue Cross and Blue Shield (Anthem) June 2021 edition of Provider News, Anthem and AIM Specialty Health ® (AIM), a separate company, are expanding their relationship to include additional services. Effective July 19, 2021, Anthem and AIM will launch a new back pain guide program for Anthem fully insured members. The new back pain guide program will identify members that are experiencing back pain or are at risk for complications related to back pain conditions and help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.
Our targeting management process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors
- Risk stratification to ensure the appropriate level of support is provided
- Targeted outreach to members through our digital engagement platform, email and calls
- Customized education and support of provider treatments based on member’s specific needs
- Education about the availability of supportive services such as behavioral health as appropriate
AIM back pain program educational information
The AIM back pain guide program microsite helps you learn more and access helpful information and tools such as program information and FAQs. Anthem also invites you to take advantage of a free informational webinar that will introduce you to the program. Go to the AIM back pain guide program microsite to access helpful information and register for an upcoming webinar.
We value your participation in our network and look forward to working with you to help improve the health of our members.
As previously communicated in the Anthem Blue Cross and Blue Shield (Anthem) May 2021 edition of Provider News, the AIM Rehabilitative program will be enhanced. Effective August 1, 2021, AIM Specialty Health ® (AIM), a separate company, will expand the AIM rehabilitative program to perform medical necessity review of the requested site of service for physical, occupational and speech therapy procedures for Anthem fully insured members.
AIM will require prior authorization for all outpatient facility and office-based rehabilitative and habiliative services. Prior authorization is recommended for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and ensure the member is receiving care at the appropriate site of service early in the process. After the evaluation, ongoing services will be subject to site of care review and require prior authorization, including post service review which may result in a denial of coverage for not medically necessary for the site of care. Requests that are not medically necessary at a hospital site may be approved for coverage at a free standing or office-based setting. AIM will use the following Anthem clinical UM guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. The clinical criteria to be used for these reviews can be found on the anthem.com clinical UM guidelines page. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, or services with diagnosis of autism.
AIM will begin accepting prior authorization requests on July 19, 2021 for services provided on or after August 1, 2021. Prior authorization requests may be submitted via the AIM ProviderPortalSM or by calling 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET. Monday through Friday.
AIM rehabilitation educational information
The AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists and CPT code lists. Anthem also invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal. Go to the AIM Rehabilitation microsite to access helpful information and register for an upcoming webinar on July 8th or 27th at 3:00 p.m. ET. If you have previously registered for other services managed by AIM, there is no need to register again.
We value your participation in our network and look forward to working with you to help improve the health of our members.
For more than a decade, Blue Precision, Anthem Blue Cross and Blue Shield’s physician transparency program, has recognized specialists for meeting or exceeding established quality and cost effectiveness measures. Thank you to all those physicians participating in our networks and for the care you provide to our members.
Anthem is announcing that we have made the decision to retire our Blue Precision program effective December 31, 2021. Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.
Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare.
As we previously communicated, the Anthem Designated Specialty Pharmacy Network requires providers who are not part of the Designated Specialty Pharmacy Network to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through CVS Specialty Pharmacy.
This update is to advise of the following changes:
Effective for dates of service on and after October 1, 2021, the following specialty pharmacy medications will be added to the Designated Medical Specialty Pharmacy drug list. Accordingly, hospitals that are not in the Designated Specialty Pharmacy Network will be required to acquire these specialty medications administered in the hospital outpatient setting from CVS Specialty Pharmacy.
HCPCS
|
Description
|
Brand Name
|
Q5117
|
INJECTION, TRASTUZUMAB-ANNS, BIOSIMILAR 10MG
|
Kanjinti
|
J1558
|
INJECTION, IMMUNE GLOBULIN 100MG
|
Xembify
|
Q5123
|
INJECTION, RITUXIMAB-ARRX, BIOSIMILAR
|
Riabni
|
To access the current Designated Medical Specialty Pharmacy drug list, please visit anthem.com, select Providers, select Forms and Guides (under the Provider Resources column), select Georgia, scroll down and select Pharmacy in the Category drop down. The Designated Medical Specialty Pharmacy drug list may be updated periodically by Anthem.
If you have questions or would like to discuss the terms and conditions to be included as a Designated Specialty Pharmacy Network provider, please contact your local Anthem network consultant. Thank you for your continued participation in the Anthem networks and the services you provide to our members.
Prior authorization updates
Effective for dates of service on and after October 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, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
*ING-CC-0195
|
J3490, J9999, C9399, J3590
|
Abecma
|
* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
Step therapy updates
Effective for dates of service on and after October 1, 2021, 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.
To access the Clinical Criteria information, please click here.
Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS Codes
|
ING-CC-0020
|
Non-preferred
|
Tysabri
|
J2323
|
This is an update to the article published in the April 2021 edition of Provider News regarding Site of Care medical necessity reviews for long-acting colony-stimulating factors.
The program will no longer begin on August 1, 2021.
Please see below for the complete updated notice.
This service will no longer be in effect on or after August 1, 2021 for medical necessity review of the site of care that was to be required for the following long-acting colony-stimulating factors for oncology indications for Anthem commercial plan members.
- Neulasta® & Neulasta Onpro® (pegfilgrastim)
- Fulphila® (pegfilgrastim-jmdb)
- Udenyca® (pegfilgrastim-cbqv)
- Ziextenzo® (pegfilgrastim-bmez)
- Nyvepria™ (pegfilgrastim-apgf)
Submit a request for review
There will be no changes for ordering providers whom submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after August 1, 2021 to AIM in one of the following ways:
- Access AIM 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.
Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare supplemental plans. Providers can view prior authorization requirements for Anthem Blue Cross and Blue Shield (Anthem) members on the clinical criteria webpage.
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the provider service phone number on the member’s ID card.
Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “site of care.”
As part of our ongoing quality improvement efforts, Anthem Blue Cross and Blue Shield (Anthem) is updating our precertification processes for certain specialty medications. Effective August 2021, we may request additional documentation for impacted medications to determine medical necessity.
Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.
Should you have any questions, please refer to our Clinical Criteria policy webpage for specific medication criteria details, including documentation requirements.
Impacted Policy
|
Impacted Medication(s)
|
ING-CC-0153: Adakveo (crizanlizumab)
|
Adakveo
|
ING-CC-0065: Agents for Hemophiilia A and von Willebrand Disease
|
Advate, Adynovate, Afstyla, Alphanate, Eloctate, Esperoct, Helixate FS, Hemlibra, Hemofil-M, Humate-P, Jivi, Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha
|
ING-CC-0148: Agents for Hemophilia B
|
Alphanine SD, Alprolix, Bebulin, Benefix, Idelvion, Ixinity, Mononine, Profilnine SD, Rebinyn, Rixubis
|
ING-CC-0025: Aldurazyme (laronidase)
|
Aldurazyme
|
ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy
|
Aralast, Glassia, Prolastin-C, Zemaira
|
ING-CC-0028: Benlysta (belimumab)
|
Benlysta
|
ING-CC-0012: Brineura (cerliponase alfa)
|
Brineura
|
ING-CC-0137: Cablivi (caplacizumab-yhdp)
|
Cablivi
|
ING-CC-0041: Complement Inhibitors
|
Soliris, Ultomiris
|
ING-CC-0081: Crysvita (burosumab-twza)
|
Crysvita
|
ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)
|
Duopa
|
ING-CC-0029: Dupixent (dupilumab)
|
Dupixent
|
ING-CC-0069: Egrifta (tesamorelin)
|
Egrifta
|
ING-CC-0024: Elaprase (idursufase)
|
Elaprase
|
ING-CC-0173: Enspryng (satralizumab-mwge)
|
Enspryng
|
ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease
|
Cerezyme, Elelyso, Vpriv
|
ING-CC-0044: Exondys 51 (eteplirsen)
|
Exondys 51
|
ING-CC-0021: Fabrazyme (agalsidase beta)
|
Fabrazyme
|
ING-CC-0068: Growth hormone
|
Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive
|
ING-CC-0034: Hereditary Angioedema Agents
|
Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro
|
ING-CC-0188: Imcivree (setmelanotide)
|
Imcivree
|
ING-CC-0070: Jetrea (ocriplasmin)
|
Jetrea
|
ING-CC-0037: Kanuma (sebelipase alfa)
|
Kanuma
|
ING-CC-0057: Krystexxa (pegloticase)
|
Krystexxa
|
ING-CC-0018: Lumizyme (alglucosidase alfa)
|
Lumizyme
|
ING-CC-0013: Mepsevii (vestronidase alfa)
|
Mepsevii
|
ING-CC-0043: Monoclonal Antibodies to Interleukin-5
|
Cinqair, Fasenra, Nucala
|
ING-CC-0023: Naglazyme (galsulfase)
|
Naglazyme
|
ING-CC-0111: Nplate (romiplostim)
|
Nplate
|
ING-CC-0082: Onpattro (patisiran)
|
Onpattro
|
ING-CC-0077: Palynziq (pegvaliase-pqpz)
|
Palynziq
|
ING-CC-0049: Radicava (edaravone)
|
Radicava
|
ING-CC-0156: Reblozyl (luspatercept)
|
Reblozyl
|
ING-CC-0159: Scenesse (afamelanotide)
|
Scenesse
|
ING-CC-0149: Select Clotting Agents for Bleeding Disorders
|
Feiba, Novoseven
|
ING-CC-0079: Strensiq (asfotase alfa)
|
Strensiq
|
ING-CC-0008: Subcutaneous Hormonal Implants
|
Testopel
|
ING-CC-0084: Tegsedi (inotersen)
|
Tegsedi
|
ING-CC-0162: Tepezza (teprotumumab-trbw)
|
Tepezza
|
ING-CC-0170: Uplizna (inebilizumab)
|
Uplizna
|
ING-CC-0172: Viltepso (viltolarsen)
|
Viltepso
|
ING-CC-0022: Vimizim (elosulfase alfa)
|
Vimizim
|
ING-CC-0152: Vyondys 53 (golodirsen)
|
Vyondys 53
|
ING-CC-0017: Xiaflex (clostridial collagenase histolyticum) injection
|
Xiaflex
|
ING-CC-0033: Xolair (omalizumab)
|
Xolair
|
Medicare Advantage
CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.
The clinical data acquisition group for Anthem Blue Cross and Blue Shield (Anthem) integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:
- Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
- Proactively manage care transitions to avoid waste.
- Close care gaps and educate members about appropriate care settings.
Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.
Email the clinical data and analytics team at ADT_Intake@Anthem.com to get started today.
Medicare Advantage
CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.
The clinical data acquisition group for Anthem Blue Cross and Blue Shield (Anthem) integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:
- Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
- Proactively manage care transitions to avoid waste.
- Close care gaps and educate members about appropriate care settings.
Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.
Email the clinical data and analytics team at ADT_Intake@Anthem.com to get started today.
ABSCRNU-0217-21 Medicare Advantage
On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised, or reviewed to support clinical coding edits.
Visit clinical criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of clinical criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The clinical criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
Effective date
|
Document number
|
clinical criteria title
|
New or revised
|
July 16, 2021
|
ING-CC-0195*
|
Abecma (idecabtagene vicleucel)
|
New
|
July 16, 2021
|
ING-CC-0191*
|
Pepaxto (melphalan flufenamide; melflufen)
|
New
|
July 16, 2021
|
ING-CC-0192*
|
Cosela (trilaciclib)
|
New
|
July 16, 2021
|
ING-CC-0193*
|
Evkeeza (evinacumab)
|
New
|
July 16, 2021
|
ING-CC-0194*
|
Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
|
New
|
July 16, 2021
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
July 16, 2021
|
ING-CC-0064
|
Interleukin-1 Inhibitors
|
Revised
|
July 16, 2021
|
ING-CC-0159*
|
Scenesse (afamelanotide)
|
Revised
|
July 16, 2021
|
ING-CC-0151
|
Yescarta (axicabtagene ciloleucel)
|
Revised
|
July 16, 2021
|
ING-CC-0145*
|
Libtayo (cemiplimab-rwlc)
|
Revised
|
July 16, 2021
|
ING-CC-0130*
|
Imfinzi (durvalumab)
|
Revised
|
July 16, 2021
|
ING-CC-0127
|
Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
|
Revised
|
July 16, 2021
|
ING-CC-0075*
|
Rituximab Agents for Non-Oncologic Indications
|
Revised
|
Medicare Advantage
On October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Anthem Blue Cross and Blue Shield. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage.
Noncompliance with new requirements may result in denied claims.
PA requirements will be added for the following codes:
- A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
- A0428 — ambulance service, basic life support, nonemergency transport (BLS)
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at availity.com or on the provider website at anthem.com/medicareprovider > Login. Contracted and noncontracted providers unable to access Availity can call the Provider Services located on the back of their patient’s member ID card for PA requirements.
Medicare Advantage
Help increase your vaccination rates and close gaps-in-care with these tools and strategies
Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.
Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:
- Address disparities for vaccine-preventable diseases.
- Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
- Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
- Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.
Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.
Medicare Advantage
(Effective 10/01/21)
Anthem Blue Cross and Blue Shield does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate.
Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.
For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at anthem.com/medicareprovider.
ABSCRNU-0212-21
|