Provider News GeorgiaMarch 2021 Anthem Provider News - GeorgiaAs of November 1, 2020, AIM Specialty Health ® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Anthem fully insured members and some ASO groups.
Effective March 14, 2021, the AIM Small Joint Surgery Guideline has been updated with the following:
- Clarified requirements for imaging reports.
- Removed radiographic requirement for confirmation of lesser toe deformities.
- Ankle arthrodesis and total ankle arthroplasty added as new indications for revision of failed previous reconstructions.
- Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis.
- Clarified contraindications only apply to total ankle arthroplasty.
Providers should continue to submit prior authorization review requests to AIM using 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 Portal at availity.com
- Call the AIM toll-free number at 866-714-1103, Monday through Friday 8:30 a.m.–7:00 p.m. ET.
For questions, please contact the provider number on the back of the member ID card.
In April, Anthem is replacing its current data management system for Georgia providers. The new system uses advanced technology that will significantly improve provider data accuracy; enhancing the overall provider experience. New system features will strengthen Anthem’s ability to match submitted claims to accurate pricing and processing.
New Provider Data Maintenance coming soon.
Once the new data management system is fully operational, Anthem will begin implementing the second stage of our systems improvement plan which includes integration with Availity Provider Data Management (PDM) functionality. Through this tool, providers can view, maintain, update, and attest provider demographic information is accurate for Anthem (and other health plans) in one easy-to-use portal. The PDM tool also features our simplified quick verification process, which allows providers to complete required verifications online – eliminating the need to fax or email. This second stage will roll out in phases beginning in June.
Get ready for the change.
For those providers not already enrolled in Availity, we strongly encourage you to get started right away. Go to Availity.com to register and to find other helpful information about using Availity. Availity is Anthem’s secure provider portal platform where providers can enjoy the convenience of digital transactions including prior authorization submission, claims submission, as well as benefit and eligibility information.
System upgrades special notice.
Anthem will be implementing the above mentioned provider management system upgrade April 10 through April 16, 2021. Provider demographic updates submitted during this time will be processed after April 16, 2021. Providers should not see Anthem members prior to receiving notification that your update is finalized for the following transaction types:
- Address - Add Location
- Network Participation
- National Provider Identifier (NPI)
- Tax Identification Number (TIN)
- Update Provider Name
As a reminder, if services are rendered to an Anthem member and claims are filed prior to the receipt of the completion date notification, Anthem is not obligated to adjust the affected claims nor are providers permitted to balance bill the member.
To help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions. Submitting an itemized bill (unsolicited* medical attachment) for a high dollar claim just got easier!
To submit an itemized bill (unsolicited medical attachment):
- Log in to Availity Portal
- Select Claims & Payments | Attachments – New
- Select Send Attachment
- Under Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK. (see example below)
Providers can also submit a claim attachment using the Availity Portal for solicited** medical attachments.
To submit supporting documentation in response to a formal (solicited) request from the payer:
- Log in to Availity Portal
- Select Claims & Payments | Attachments – New
- Select Send Attachment
- Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number (see example below)
- Add supporting documentation and reason
- Submit
Additionally, if you attended a previous webinar, we have updated information on submitting an EDI 837 batch that includes a PWK segment in loops 2300/2400. The update is regarding the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.
What does this mean for you?
You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim and no additional face sheet or coversheet is needed.
Here are the steps:
- Log in to Availity Portal
- Select Claims & Payments I Attachments - New
- From the Inbox tab, select the appropriate claim or open the request in your work queue
- Add files with supporting documentation
- Submit
Get trained
- Attend an Availity-hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity here, or
- Log into availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).
- Search by keyword (Medattach) to find on-demand and live training options
- Click Enroll to enroll for a course and then go to your Dashboard to access it any time
Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.
A new facility reimbursement policy titled Place of Service Evaluation and Management will be implemented beginning with dates of service on, or after June 1, 2021. The policy outlines where Evaluation and Management (E&M) services can be rendered by office, professional building, medical office building, clinic or a space owned by a hospital or an institutional provider, other than the primary structure on the campus of the hospital or institutional provider, or rented by a professional from the hospital or an institutional provider. E&M Services must be billed on a CMS-1500 claim form and are not reimbursable if they are billed on a UB-04 claim form.
For more information about this policy, visit the Reimbursement page on our anthem.com/provider website.
Starting May 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will implement a new prior authorization for HIV medications to help ensure patients are not receiving therapeutic duplications when taking certain combinations. Providers and members expected to be impacted by this policy will receive advanced notice by mail.
In order for members to continue to receive coverage for the drug combination, providers must submit a separate prior authorization form for each drug and provide the medical necessity rationale for why the drug combination is clinically needed.
Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.
The duplicate therapy policy may trigger as a result of one of the following drug combinations:
Duplicate Name
|
Duplicate Description
|
Example
|
Integrase stand transfer inhibitors (INSTI)
|
Two drug products each containing a drug with an INSTI mechanism of action.
|
Isentress (raltegravir) and Dovato (dolutegravir/ lamivudine).
|
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
|
Two drug products each containing a drug with an NNRTI mechanism of action.
|
Edurant (rilpivirine) and Symfi (efavirenz/lamivudine/TDF).
|
Protease inhibitors (PI)
|
Two drug products each containing a drug with a PI mechanism of action.
|
Prezcobix (darunavir/cobicistat) and Reyataz (atazanavir).
|
Nucleoside reverse transcriptase inhibitors (NRTI)
|
Two drug products that together result in four NRTI active ingredients.
|
Truvada (emtricitabine/TDF) and Biktarvy (bictegravir/ emtricitabine/TAF).
|
Boosters
|
Two drug products that result in a combination of the protease inhibitor boosters, ritonavir and cobicistat.
|
Prezcobix (darunavir/cobicistat) and Kaletra (lopinavir/ritonavir).
|
As a reminder, prior authorizations may be submitted via phone, fax, or online (through CoverMyMeds.com). If you have any questions regarding this policy, please contact your local provider network consultant.
Prior authorization updates
Effective for dates of service on and after June 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-0185
|
J3490
C9399
|
Oxlumo
|
**ING-CC-0184
|
J3490
J3590
J9999
|
Danyelza
|
** Oncology use is managed by AIM.* Non-oncology use is managed by the medical specialty drug review team.
Prior authorization update – change in effective date
Please note the change in effective date of prior authorization for injectable iron deficiency anemia products listed below.
The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our prior authorization review process. The previous effective date was March 1, 2021.
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-0182
|
J1756
|
Venofer
|
*ING-CC-0182
|
J2916
|
Ferrlecit
|
*ING-CC-0182
|
J1750
|
Infed
|
*ING-CC-0182
|
J1439
|
Injectafer
|
*ING-CC-0182
|
Q0138
|
Feraheme
|
*ING-CC-0182
|
J1437
|
Monoferric
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Step therapy update – change in effective date
Please note the change in the effective date of step therapy for injectable iron deficiency anemia products.
The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our existing specialty pharmacy medical step therapy review process. The previous effective date was March 1, 2021.
To access the Clinical Criteria information with step therapy drug lists, 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
|
Status
|
Drug(s)
|
HCPCS Codes
|
*ING-CC-0182
|
Preferred
|
Venofer
|
J1756
|
*ING-CC-0182
|
Preferred
|
Ferrlecit
|
J2916
|
*ING-CC-0182
|
Preferred
|
Infed
|
J1750
|
*ING-CC-0182
|
Non-preferred
|
Injectafer
|
J1439
|
*ING-CC-0182
|
Non-preferred
|
Feraheme
|
Q0138
|
*ING-CC-0182
|
Non-preferred
|
Monoferric
|
J1437
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Prior authorization update – change in code list
In a recent notification, we shared that effective April 1, 2021 the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization process at this time.
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
|
Markets Impacted
|
*ING-CC-0095
|
J9041
|
Velcade (Bortezomib)
|
CA, CT, ME, NH IN, KY, MO, NY, OH, WI, VA, GA
|
**ING-CC-0095
|
J9041
|
Velcade (Bortezomib)
|
CA, CT, ME, NH IN, KY, MO, NY, OH, WI, VA, GA
|
*ING-CC-0095
|
J9044
|
Bortezomib
|
CA, CT, ME, NH, IN, KY, MO, NY, OH, WI, VA, GA
|
**ING-CC-0095
|
J9044
|
Bortezomib
|
CA, CT, ME, NH, IN, KY, MO, NY, OH, WI, VA, GA
|
*ING-CC-0093
|
J9171
|
Docetaxel
|
CT, ME, NH, IN, KY, MO, NY, NE, OH, WI, VA, GA
|
**ING-CC-0093
|
J9171
|
Docetaxel
|
CT, ME, NH, IN, KY, MO, NY, NE, OH, WI, VA, GA
|
*Non-oncology use is managed by Anthem’s medical specialty drug review team.
**Oncology use is managed by AIM.
Prior authorization update – medical specialty pharmacy update
In an effort to simplify care and support our providers, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions, effective May 1, 2021.
Drug
|
Code
|
Code description
|
*Avastin
|
C9257
J9035
|
intravitreal bevacizumab
|
*Mvasi
|
Q5107
|
bevacizumab-awwb
|
*Zirabev
|
Q5118
|
bevacizumab-bvzr
|
*Non-oncology use is managed by Anthem’s medical specialty drug review team.
Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.
Effective with dates of service on or after June 1, 2021, medical necessity review of the site of care is 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)
The review will be administered by AIM Specialty Health® (AIM).
AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit anthem.com/provider and visit the Medical Policies & Clinical UM Guidelines page. Type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.
The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.
Submit a request for review
Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 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 members on the anthem.com/provider Pharmacy Clinical Criteria page.
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.”
Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.
Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC are committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem and AMH Health have the answers before you ask the questions. With an initial focus on claim-level insights, Anthem and AMH Health have streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.
Access the Claims Status Listing on Payer Spaces from anthem.com/medicareprovider using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.
Claim resolution daily
Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim
status changes, other claims needing resolution are added, and claims are resolved faster.
Anthem and AMH Health made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.
Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem and AMH Health are using digital technology to improve the healthcare experience. If you have questions, please reach out to your local provider network consultant.
The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit anthem.com/ca_search.html.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
- Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
- *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
- Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and
anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
- *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
- Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
- Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
- *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
- Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
- *CG-LAB-15 – Red Blood Cell Folic Acid Testing
- RBC folic acid testing is considered not medically necessary in all cases
- *CG-LAB-16 – Serum Amylase Testing
- Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
- *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
- Added the Afirma Xpression Atlas as not medically necessary
- 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
- A new Medical Policy was created from content contained in DME.00011.
- There are no changes to the policy content.
- Publish date is December 16, 2020.
- CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
- A new Clinical Guideline was created from content contained in GENE.00026.
- There are no changes to the guideline content.
- Publish date is December 16, 2020.
Medical Policies
On November 5, 2020, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect March 8, 2021.
Publish date
|
Medical Policy number
|
Medical Policy title
|
New or revised
|
12/16/2020
|
*GENE.00055
|
Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
|
New
|
12/16/2020
|
*LAB.00037
|
Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
|
New
|
11/12/2020
|
ANC.00009
|
Cosmetic and Reconstructive Services of the Trunk and Groin
|
Revised
|
12/16/2020
|
*DME.00011
|
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
|
Revised
|
11/12/2020
|
GENE.00052
|
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
|
Revised
|
11/12/2020
|
MED.00129
|
Gene Therapy for Spinal Muscular Atrophy
|
Revised
|
12/16/2020
|
SURG.00011
|
Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised
|
12/16/2020
|
*SURG.00062
|
Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
|
Revised
|
Clinical UM Guidelines
On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020. These guidelines take effect March 8, 2021.
Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or revised
|
12/16/2020
|
*CG-LAB-15
|
Red Blood Cell Folic Acid Testing
|
New
|
12/16/2020
|
*CG-LAB-16
|
Serum Amylase Testing
|
New
|
11/12/2020
|
CG-DME-42
|
Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
|
Revised
|
12/16/2020
|
*CG-GENE-04
|
Molecular Marker Evaluation of Thyroid Nodules
|
Revised
|
12/16/2020
|
CG-GENE-18
|
Genetic Testing for TP53 Mutations
|
Revised
|
12/16/2020
|
CG-GENE-20
|
Epidermal Growth Factor Receptor (EGFR) Testing
|
Revised
|
11/12/2020
|
CG-MED-87
|
Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
|
Revised
|
Anthem Blue Cross and Blue Shield (Anthem) 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 use 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.
|