May 2021 Anthem Provider News - Georgia

Contents

Behavioral HealthCommercialMay 1, 2021

Fewer repeat visits to the emergency room with follow-up care

Policy UpdatesCommercialMay 1, 2021

Georgia Anthem preapproval list change notification 5/1/2021

Medical Policy & Clinical GuidelinesCommercialMay 1, 2021

Clinical guideline update

Medical Policy & Clinical GuidelinesCommercialMay 1, 2021

Update to AIM Specialty Health Oncologic Imaging clinical appropriateness guidelines

Reimbursement PoliciesCommercialMay 1, 2021

Reimbursement policy update: frequency editing (professional)

Reimbursement PoliciesCommercialMay 1, 2021

Reimbursement policy reminder: readmission (facility)

State & FederalMedicare AdvantageMay 1, 2021

Keep up with Medicare news

State & FederalMedicare AdvantageMay 1, 2021

Maximizing efficient, high quality COVID-19 screenings

AdministrativeCommercialMay 1, 2021

Referring to network DME providers for negative pressure wound therapy helps members save on out-of-pocket costs

Often, healthcare costs incurred by Anthem Blue Cross and Blue Shield (“Anthem”) members are a result of recommendations made by their physicians. As an Anthem participating physician, you have the ability to help reduce your patients’ healthcare costs. Choices, such as where to refer a member for negative pressure wound therapy, can have a significant impact on your patients’ ultimate out-of-pocket liability. We are sharing the following information with you for consideration when referring patients for negative pressure wound therapy.

 

Our members, your patients, often participate in health benefit plans that may have coinsurance or deductibles. Your patients may experience significant differences in cost depending on which negative pressure wound therapy providers the members are referred to. The following table provides a sample listing of Anthem high quality, low cost national negative pressure wound therapy providers. Referring to these providers will likely lower your patients’ out-of-pocket costs. 

Provider

Phone number

Apria

1-800-780-1228

Rotech

1-844-592-5068

 

You can find all of Anthem’s participating durable medical equipment (DME) orthotics and prosthetics providers, at “Find Care,” Anthem’s doctor finder and transparency tool, at anthem.com.

 

Anthem is committed to seeking ways to reduce healthcare costs, and your referrals to network- participating providers can help make a difference.  We appreciate your partnership in considering the financial impact to your patients, our members, especially during these challenging economic times.

 

If you have questions, please contact your local network relations consultant or call provider services.


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AdministrativeCommercialMay 1, 2021

Send larger digital attachments through Availity

After receiving your feedback, we expanded our server to meet your need to upload larger files to our digital attachment tool, through Availity. You can now upload files up to 100 megabytes, eliminating the need to mail or fax.

Use the attachment tool to upload:

  • Medical records
  • Itemized bills
  • Payment dispute
  • EOB
  • General correspondence
  • Consent forms


The digital attachment tool file size expansion is just one example of how Anthem is using digital technology to improve the healthcare experience, with a goal to save you valuable time.

Access the attachment tool through Availity.com. From the Claims & Payments header, select Attachments – New. For more information about how to setup electronic attachments, use the Getting Started Guide: Select Help & Training>Find Help and then the Attachments topic in Contents. Once logged on you can also access the Getting Started Guide using this link.

For information about setting up for Program Integrity attachments, once logged on to Availity, use this link.

You can also access Program Integrity attachment information from the Custom Learning Center: Payer Spaces>Custom Learning Center>Electronic Medical Records.

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AdministrativeCommercialMay 1, 2021

Provider bulletins for medical and itemized bill attachments

Our organization is working robustly to establish Anthem Blue Cross and Blue Shield (Anthem) as a digital-first enterprise and to streamline your daily working tasks by using electronic functionalities. In support of the digital-first solutions we are excited to publish the first iteration of provider bulletins around submitting medical attachments and itemized bills in partnership with Availity.

The objective of the bulletins is to provide a simple guide for you and your staff with step-by-step navigation instructions, where to find help and training with medical attachments.

The provider bulletins are posted on the Custom Learning Center (CLC) in Payer Spaces under the Resources tab for you to access and download.

Please encourage your staff who have questions on the process or who are not submitting claim attachments electronically to review these valuable resources for assistance.

 

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AdministrativeCommercialMay 1, 2021

May is national high blood pressure education month

In honor of National High Blood Pressure Education Month, learn more about CDC’s WISEWOMAN program: Well-Integrated Screening and Evaluation for WOMen Across the Nation. The aim of this program is to improve the delivery of heart disease and stroke prevention services for underserved women, aged 40-64 years. The program focuses on cardiovascular disease risk factors, specifically improving high blood pressure.1 To learn even more about WISEWOMAN, visit the CDC website.


Resources for your Patients
If your patient is one of the tens of millions of American adults who have hypertension, you know encouraging a healthier lifestyle and prescribing the right medications is important to managing the condition. But, if you would like to provide additional information about high blood pressure to your patients, take advantage of the helpful resources available to healthcare professionals through the CDC. The Hypertension Communications Kit provides blood pressure logs, tip sheets, and more. Hypertension Patient Education Handouts include fact sheets, medication information and dozens of useful tools.


Meeting the HEDIS® measure?

Controlling High Blood Pressure (CBP) assesses adults ages 18-85 with a diagnosis of hypertension and whose blood pressure was properly controlled base on the following criteria

  • Adults 18-59 years of age whose blood pressure was <140/90 mm Hg
  • Adults 60-85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
  • Adults 60-85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg


Patient claims should include one systolic reading and one diastolic reading2:

CPT II Code

Most recent systolic blood pressure

3074F

<130 mm Hg

3075F

130-139 mm Hg

3077F

≥ 140 mm Hg

CPT II Code

Most recent diastolic blood pressure

3078F

<80 mm Hg

3079F

80-89 mm Hg

3080F

≥ 90 mm Hg

 

When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.

Additional tips for talking to patients

  • Continue to educate patients about the risks of hypertension
  • Encourage weight loss, regular exercise, and diet
  • Advise patients who are smoking to quit
  • Talk about chronic stress and ways to cope with it in a healthy way


1 https://www.cdc.gov/wisewoman/about.htm

2 https://www.cdc.gov/bloodpressure/index.htm

 

HEDIS@ is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

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AdministrativeCommercialMay 1, 2021

A helpful and complete guide to covered well-child visits

The American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care. Known as the “periodicity schedule,” this screenings and assessments guideline provides a comprehensive schedule for each well-child visit, from infancy.

Schedule for well-child visits


The AAP recommends that children should have a total of eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure. Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures. 

Complete coverage for well-child visits regardless of when visit is received

Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.

HEDIS® measures W30 and WCV
Well-child visits in the first 30 months of life (W30)
Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:

  1. Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
  2. Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.

Child and adolescent well-care visits

Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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ATTACHMENTS (available on web): well child schedule.jpg (jpg - 0.03mb)

AdministrativeCommercialMay 1, 2021

Resources to support diverse patients and communities

We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well. The current health crisis illuminates this quite clearly. It is imperative to offer care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield (Anthem) is committed to supporting our providers in this effort. 

 

MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:

  • Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers to enhance care.
  • Real life stories about diverse patients and the unique challenges they face.
  • Tips and techniques for working with diverse patients to promote improvement in health outcomes.

 

Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

 

While there is no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.

 

Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.

 

My Diverse Patients:


Stronger Together health equity resources:


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AdministrativeCommercialMay 1, 2021

Digital online scheduling feature now available in the Availity portal

The Appointment Scheduler application in Availity Payer Spaces is an online appointment-scheduling feature that allows providers to manage appointments with patients that may want to schedule appointments directly. Providers can manage patients’ appointment requests and maintain their appointment availability.

Providers can receive new appointment requests from active members, along with important information like the member’s ID number, contact information and any special health information they want the doctor to know. Providers can modify or deactivate their availability at any time. Availity users with the role of “office staff” can set up physicians in the practice to accept online appointment requests.

Enrollment for Appointment Scheduler is easy. To access Appointment Scheduler in the Availity portal: Availity > Payer Spaces > Select Payer Tile > Applications

Appointment Scheduler features:

  • Manage appointment requests and view physician availability
  • Configure appointment availability
  • Notification of new visit requests on Availity Notification Center and via email
  • Members are notified directly via text or email once appointment is confirmed
  • Send patient reminders via the Appointment Scheduler application
  • Customize office locations and available times, as well as the types of appointments accepted


Visit the Appointment Scheduler application in the Availity portal today.



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ATTACHMENTS (available on web): Appointment scheduler image.jpg (jpg - 0.1mb)

AdministrativeCommercialMay 1, 2021

2021 Affirmative statement regarding utilization management decisions

All associates who make utilization management decisions are required to adhere to the following principles:
  • Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
  • We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support denials of benefits.
  • Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization, or create barriers to care and service.

 

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AdministrativeCommercialMay 1, 2021

Anthem’s Digital Provider Enrollment application now available for providers who do not use CAQH

Anthem continues to make it easier and more convenient to become a participating provider. The Digital Provider Enrollment application has been designed to speed up the enrollment process, allow providers to submit data at one time, and obtain real-time updates on the status of an application.

 

Access to the application is available through Availity, Anthem’s secure web-based provider portal.

New and current Availity users should ensure their user ID has the correct access. Please ensure that you have been assigned to Provider Enrollment.

 

Digital provider enrollment offers many benefits:

  • Now, non-credentialed provider types can also use the digital enrollment process
  • Continues to support enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with Anthem.
  • New individual providers or groups can request a contract.
  • Existing groups can add providers to their existing contract.
  • Providers can check the status of an application in real-time using the enrollment dashboard.

 

To use the new Digital Provider Enrollment application, please ensure your provider data on CAQH is current and in a complete or re-attested status, then log into Availity and use the following navigation: Choose Georgia > Payer Spaces > Provider Enrollment.

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AdministrativeCommercialMay 1, 2021

Anthem’s new strategic provider system launched in April

As you know, in April, Anthem replaced its legacy internal data management system for Georgia providers. This new investment in advanced technology will significantly improve provider data accuracy and transparency, enhancing the overall provider experience. New system features strengthen Anthem’s ability to match submitted claims for more accurate pricing and processing.

Next steps: new provider data maintenance coming soon.

Beginning in June, the second phase of our improvement, integration with Availity Portal Provider Data Management (PDM) functionality, will roll out in phases. 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 also features our simplified quick verification process, which enables providers to complete the required verifications online – eliminating the need to fax or email.

Get ready for the change today.

If your organization is not already registered on Availity Portal, we strongly encourage you to get started right away. Your organization’s designated administrator can go to Availity.com to register and to find other helpful information about using Availity. Availity is Anthem’s secure provider portal where you can enjoy the convenience of digital transactions including prior authorization submission, claims submission and benefit and eligibility look-up.

Critical billing requirements

Claims submitted without a billing national provider identifier (NPI) will be denied. Submitting claims with complete and correct data is critical to ensure Anthem is able to process your claims efficiently and accurately. All data fields on claims are used when building your claim record. Review your billing practices carefully to ensure provider tax identification number (TIN), billing national provider identifier (NPI) and servicing provider information (if applicable) are submitted in the appropriate fields.


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AdministrativeCommercialMay 1, 2021

New Regional Vice President for Georgia Networks

Anthem Blue Cross and Blue Shield (Anthem) is pleased to announce that Kelley Sizemore has recently joined our network team as Regional Vice President for Georgia Networks.

 

Kelley has over 23 years of Healthcare experience and prior to Anthem, held leadership roles with Health Care Service Corporation, Centene and United Healthcare. 

 

Please join us in welcoming Kelley to Anthem!


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Behavioral HealthCommercialMay 1, 2021

Fewer repeat visits to the emergency room with follow-up care

According to an NCQA finding, research suggests that patients who received follow-up care after an emergency department visit for a mental health condition were less likely to have a repeat visit. Patients also benefited from follow-up care through improved physical and mental function and were more likely to stick to their follow-up care instructions.[i]

In 2019, fewer than half those prescribed follow-up care within seven days of an emergency department visit followed through with the recommended care instructions. There were significant increases in adherence to follow-up care instructions within the 30-day threshold as illustrated in the findings provided by NCQA.

Follow-up within 7 days of emergency department visit

Measurement Year

All Ages                             

 

 

 

2019

46.8%

 

 

 

2018

45.6%

 

 

 

2017

45.9%

 

 

 

 

Follow-up within 30 days of emergency department visit

Measurement Year

All Ages                             

 

 

 

2019

61.2%

 

 

 

2018

60.1%

 

 

 

2017

60.2%

 

 

 

 

Excerpt from NCQA FUM: https://www.ncqa.org/hedis/measures/followup-after-emergency-department-visit-for-mental-illness/
Follow these HEDIS® measures for additional guidance in closing the gaps in follow-up care after an emergency department visit for mental illness health conditions, alcohol or other drug abuse or disorder.

A note about telehealth

NCQA now accepts telehealth codes for behavioral health and some physical health measures. The modifiers 95 and GT are defined as telehealth services rendered via interactive audio and video telecommunications system.  CPT Codes 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 98960-98962, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99409 and 99495-99496 may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95.

 

Follow-up after emergency department visit for mental illness (FUM): The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:

  • The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
  • The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).


The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.

 

FUM billing codes

Outpatient follow-up visits CPT: 90791-2, 90832-4, 90836-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510

 

HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015

 

Mental illness diagnosis codes ICD-10: F03.9x, F20-25.xx, F28-34. xx, F39-45.xx, F48.xx, F50-53.xx, F59-60.xx, F63-66.xx, F68-69.xx, F80-82.xx, F84.xx, F88-93.xx, F95.xx, F98-99.xx

 

Intentional self-harm diagnosis codes ICD-10 example: T39.92XA

Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962

 

Telehealth modifier: 95 or GT

 

Telehealth modifier POS: 02

 

Follow-up after emergency department visit for alcohol and other drug abuse or dependence (FUA): The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. Two rates are reported:

  • The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
  • The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).


The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.

 

FUA billing codes:

Initiation, engagement and treatment follow-up visits CPT: 98960-2, 99078, 99201-5, 99211-5, 99241-5, 99341-50, 99384-7, 99394-7, 99401-4, 99408-9 99411-2, 99483, 99510

Alcohol counseling or other follow-up visits CPT: 99408-9 HCPCS: G0396-7, G0443, H0005, H0007, H0016, H0022, H0050, H2035-6, T1006, T1012 AOD

 

Medication treatment HCPCS: G2067-77, G2080, G2086-7, H0020, H0033, J0570, J0571-5, J2315, Q9991-2, S0109

 

Substance use disorder diagnosis codes ICD-10: F10-16.xx, F18-19.xx

 

Telehealth modifier: 95 or GT

 

Telephone visits: 98966 - 98968, 99441- 99443

 

Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99408-99409, 98960-98962

 

Telehealth modifier POS: 02

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

[1] https://www.ncqa.org/hedis/measures/follow-up-after-emergency-department-visit-for-mental-illness/

 

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Policy UpdatesCommercialMay 1, 2021

Georgia Anthem preapproval list change notification 5/1/2021

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 preapproval 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 preapproval 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 provider portal 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
  • Outpatient sleep testing and therapy services
  • Cancer care quality program
  • Musculoskeletal (for fully insured)
  • Upper gastrointestinal endoscopy


For more details on these programs, please visit the AIM Specialty Health® site at aimspecialtyhealth.com/marketing/guidelines/185/index.html. 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 by through 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

CG-SURG-49

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 0505T, 0620T

Added 8/1/2021

 

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Medical Policy & Clinical GuidelinesCommercialMay 1, 2021

Clinical guideline update

Anthem Blue Cross and Blue Shield (Anthem) is committed to reducing cost while improving health outcomes. To that end, effective August 1, 2021 Anthem will be implementing CG-SURG-49 Endovascular techniques (percutaneous or open exposure) for arterial revascularization of the lower extremities for our commercial business.   

 

The clinical UM guideline is available for review on our website at anthem.com.


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Medical Policy & Clinical GuidelinesCommercialMay 1, 2021

Update to AIM Specialty Health Oncologic Imaging clinical appropriateness guidelines

Effective for dates of service on and after May 1, 2021, the following update will apply to the AIM Oncologic Imaging clinical appropriateness guideline as recommended by the United States Preventive Services Taskforce lung cancer: screening statement.
  • Expanded low-dose CT screening for ages equal to or greater than 50 and less than or equal to 80 AND 20 or greater pack-year history of cigarette smoking.

 

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 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.

 

For 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.

 

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Reimbursement PoliciesCommercialMay 1, 2021

Reimbursement policy update: claims requiring additional documentation (facility)

As a reminder, Anthem Blue Cross and Blue Shield (Anthem) announced the delay of a change to our facility reimbursement policy Claims Requiring Additional Documentation in the October 2020 edition of the Provider News. The change would have required facilities to submit an itemized bill with outpatient facility claims reimbursed at a percent of charge with billed charges above $20,000. We are raising the billed charges threshold to $50,000 for outpatient and will now implement with dates of service on or after August 1, 2021.

 

In addition, we are raising the itemized bill requirement for inpatient stay claims threshold from $40,000 to $100,000  and will now implement with dates of service on or after August 1, 2021.

 

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Reimbursement PoliciesCommercialMay 1, 2021

Reimbursement policy update: frequency editing (professional)

In the January 2021 edition of Provider News, we shared information regarding changes to the Frequency Editing professional reimbursement policy. The notice indicated that constant attendance, timed modalities for physical therapy, occupational therapy or speech therapy are limited to 4 Units or 1 hour per date of service for the same member, by the same provider, per therapy type for (97110 – 97124, 97129, 97130, 97140, 97533 – 97542, 97760 – 97763).  Upon further review, we have reconsidered our position and have removed this edit for dates of service on or after April 1, 2021. 

 

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Reimbursement PoliciesCommercialMay 1, 2021

Reimbursement policy reminder: readmission (facility)

As a reminder, Anthem Blue Cross and Blue Shield (Anthem) does not allow separate reimbursement for claims that have been identified as a readmission for the same, similar or closely-related diagnoses or condition to the same facility or another facility that (i) operates under the same Facility Agreement, (ii) has the same tax identification number as facility, or (iii) is under common ownership as facility, as further described in the existing reimbursement policy found here: Commercial Readmission Policy. If Anthem determines that this reimbursement policy has not been followed, Anthem may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Anthem, and Anthem policies.

 

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Products & ProgramsCommercialMay 1, 2021

Modification to voluntary Cancer Care Quality Program (CCQP) enhanced reimbursement to begin July 1, 2021

To more appropriately align program intention to support member care coordination, and to ensure compliance with regulatory requirements surrounding the program, Anthem Blue Cross and Blue Shield (Anthem) is amending the approach for enhanced reimbursement that accompanies selection of ‘on-pathway’ chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program. 

 

Effective July 1, 2021, enhanced reimbursements for medical oncologists selecting on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy authorization process will be adjusted for specific regimens.  

 

Impacted regimens include only select oral and hormonal agents for which a monthly in-office visit may not be required. For these impacted regimens, the optional enhanced reimbursement award, billable using S-codes for treatment planning and care coordination management for cancer, will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353).  

 

This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates. 

 

AIM/Anthem will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support. 

 

For a list of the specific regimens that will be impacted by these changes, please review the attached document titled “Single S-code eligible regimens May 2021.pdf

 

Contact your Anthem local network consultant or your oncology provider engagement liaison for more information. 

 

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Products & ProgramsCommercialMay 1, 2021

Updated AIM Rehabilitative program effective August 1, 2021: initial evaluations and site of service reviews

We are 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 August 1, 2021, AIM Specialty Health® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the initial evaluation service codes and requested site of service for physical, occupational and speech therapy procedures for Anthem Blue Cross and Blue Shield (Anthem) fully insured members, as further outlined below. 

 

AIM will continue to manage physical therapy (PT), occupational therapy (OT) and speech therapy (ST) medical necessity reviews and will require prior authorization for all outpatient facility and office-based rehabilitative and habiliative services. Prior authorization will now also be required 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. 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/provider website 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, and services with diagnosis of autism.

 

A complete list of CPT codes requiring prior authorization for the AIM Rehabilitation program is available on the AIM Rehabilitation microsite. To determine if prior authorization is needed for an Anthem member on or after August 1, 2021, providers can contact the Anthem provider services phone number on the back of the member’s ID card for benefit information. They will be informed whether the AIM Rehabilitation program applies. AIM will also have a file upload from the health plan of the in-scope membership and will not provide prior authorization for members who are out of scope. If providers use the Interactive Care Reviewer (ICR) tool on the Availity portal to pre authorize an outpatient rehabilitative or habilitative service, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests for services administered by AIM.)

 

Members included in the new program

All fully insured members currently participating in the AIM Rehabilitative program are included. Medicaid members will be included in a separate communication. The following groups are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR, and the Federal Employee Program® (FEP®). 

 

For self-funded (ASO) groups that currently participate in the AIM Rehabilitative program, the program will be offered to add to their members’ benefit package.

 

For services provided on or after August 1, 2021, ordering and servicing providers may begin contacting AIM beginning July 19th for review. 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 web portal at availity.com.
  • Call the AIM Contact Center toll-free number at 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

Initiating a request on AIM’s ProviderPortal for PT/OT/ST and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the order ID, the number of visits and valid time frame. The AIM Rehabilitation program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.

 

AIM Rehabilitation training webinars                                                                         

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM.  Go to the AIM Rehabilitation microsite to register for an upcoming webinar on June 22nd, July 8th or July 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.

 

1121-0521-PN-GA

PharmacyCommercialMay 1, 2021

Updates for specialty pharmacy are available (May 2021)

Prior authorization updates

Effective for dates of service on and after August 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-0186

J3490, J3590, J9999

Margenza

*ING-CC-0187

J3490, J3590, J9999

Breyanzi

*ING-CC-0188

J3490, J3590

Imcivree

*ING-CC-0189

J3490, J3590, C9399

Amondys 45

*ING-CC-0190

J3490, J3590, C9399

Nulibry

**ING-CC-0094

J9304

Pemfexy

**ING-CC-0075

J3590, J9999, C9399

Riabni

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Prior authorization update – change in clinical criteria

Coding update: Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.

 

Quantity limit updates

Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the clinical criteria information, 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-0189

J3490. J3590, C9399

Amondys 45

*ING-CC-0190

J3490, J3590, C9399

Nulibry

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

1138-0521-PN-GA

PharmacyCommercialMay 1, 2021

Anthem clinical criteria updates for specialty pharmacy are available

Effective for dates of service on and after August 1, 2021, the following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

 

Access the clinical criteria document information.

 

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Drugs used for the treatment of oncology will be managed by AIM Specialty Health® (AIM), a separate company

 

  • ING-CC-0033 Xolair (omalizumab)
  • ING-CC-0043 Monoclonal antibodies to interleukin-5
  • ING-CC-0119 Yervoy (ipilimumab)
  • ING-CC-0125 Opdivo (nivolumab)
  • ING-CC-0157 Padcev (enfortumab vedotin)
  • ING-CC-0189 Amondys 45 (casimersen)
  • ING-CC-0190 Nulibry (fosdenopterin)

 

1105-0521-PN-GA

State & FederalMedicare AdvantageMay 1, 2021

Keep up with Medicare news

State & FederalMedicare AdvantageMay 1, 2021

Maximizing efficient, high quality COVID-19 screenings

Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross and Blue Shield (Anthem)-contracted laboratories and identify the proper CPT® codes to use. Contact your Anthem representative for additional information or visit anthem.com/medicareprovider.

 

Refer patients to anthem.com/coronavirus to find convenient testing locations

If an Anthem member requests a COVID-19 test, you may refer them to Anthem to find a testing location near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:

  • Appointment or walk-in
  • Drive through service
  • Rapid test results
  • Antibody testing
  • Testing for children

 

Consider Antigen testing as an option when rapid results are needed

Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), (for example, PCR). Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.

 

Send swab tests to Anthem-contracted laboratories

When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high-value healthcare.

In-network lab

Telephone

Website

Eurofins NTD

888-683-5227

ntd-eurofins.com

Eurofins Viracor

800-305-5198

viracor-eurofins.com/test-menu/8300-coronavirus-covid-19-sars-cov-2-rt-pcr

Eurofins Boston Heart

877-425-1252

bostonheartdiagnostics.com

Fulgent Therapeutics

626-350-0537

fulgentgenetics.com/covid19

Invitae Corporation

650-466-7242

invitae.com/en/partners

Gravity Diagnostics

855-841-7111

gravitydiagnostics.com/covid-19-coronavirus-testing-partners

Mako Medical Laboratories

919-351-6256

makomedical.com

 

ABSCRNU-0220-21