 Provider News GeorgiaMay 1, 2025 May 2025 Provider Newsletter Featured Articles Administrative | Commercial | May 1, 2025
GABCBS-CRCM-081389-25-CPN81360 BackgroundWe previously shared details about an enhancement to the medical claims editing system for pharmaceutical drug procedure codes. This improvement ensures that claims align with FDA‑approved or off‑label indications, based on the list of pharmaceutical compendia defined by CMS. This change aims to promote accuracy in claims and improve reimbursement efficiency. Provider impactBeginning with claims processing on or after June 1, 2025, we will introduce additional drug procedure codes into our system. Codes requiring preapproval or those tied to specific medical policies will not be affected by this update. Note: A drug procedure code will not be approved if the diagnosis reported is not an approved indication. If you would like your claim decision reviewed, follow the claims dispute process outlined in the provider manual. You must include relevant medical record details regarding the drug provided for faster resolution. If you have questions about this notification, contact your contract manager or provider relationship management representative. Thank you for your cooperation and commitment to improving member care. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-078848-25-CPN77148 Take your success as a care provider to the next level by managing claims online with Availity Essentials
You can benefit from:
- Supercharged claim efficiency
- Swift payments
- Paperless ease
- Cost savings
- Comprehensive support for all your healthcare claims — medical, institutional, and dental
Navigate claims effortlessly with Claims & Payments
Submit and review with ease. Get prompt claim notifications and easily attach documents.
Elevate your expertise:
What if I’m not registered for Availity Essentials?
Signing up is easy and secure if you aren’t registered to use Availity Essentials. There is no cost to register or to use any of the digital applications.
To access the registration page, go to https://Availity.com and select New to Availity? Get Started at the top of the home screen. If you have more than one TIN, ensure you have registered all TINs associated with your account.
Assistance
For assistance, contact Availity Client Services online via Help & Training > Availity Support > Contact Support > Create a case, use Chat with Support, or call Monday through Friday from 8 a.m. to 8 p.m. Eastern time at 800‑AVAILITY (282‑4548).
We're dedicated to lightening your administrative load and securing timely payments because we value you, our care provider partners. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-082273-25-CPN82130 Annual wellness and well-woman visits are covered with no member cost-sharing when provided by in-network providers for our members with Affordable Care Act (ACA)compliant plans. Individual and small group plan members are encouraged to schedule these visits within the first 90 days of their plan starting or renewing, so your practice may see an increase in requests, especially at the beginning of the second and fourth quarters. Providers can perform the annual wellness or well‑woman visit, even if it has been less than one calendar year since the last wellness visit. We ask that your practice be flexible in accommodating members wanting to schedule their visits earlier than they may have previously. The wellness or well‑woman visit claim will be processed as a preventive care service covered with no member cost share. Please note that this benefit may not apply to all health plans. You should continue to verify eligibility and benefits for all members in Availity Essentials (https://Availity.com) before providing services or receiving member copayments, deductibles, or coinsurance. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-079025-24-CPN73418 Manage your prior authorization requests with our digital tools — Availity Essentials and https://anthem.com/provider. These resources simplify requirement determination and request submissions, giving you more time to deliver effective and efficient care to our members. We encourage you to review the instructions below. Determining prior authorization requirementsAvaility Essentials: - Log in to https://Availity.com.
- If you do not already have access, select Get Started to create an account.
- Go to the Payer Spaces tab.
- Select the applicable plan.
- Select Authorization Rules Lookup.
- Enter the required provider information.
- Select Next and enter the required member information.
Note: Final determination of prior authorization requirements is completed upon submission and may differ from search results. Provider website: - Go to https://anthem.com/provider.
- Scroll down and select the applicable state.
- Scroll down to Commercial‑partnered programs and select Access the Commercial Provider site to access the Provider website homepage.
- Under the Resources heading, select Prior Authorization.
- Select the applicable state.
- Select the appropriate link based on the member’s plan.
If the member’s home plan is not with Anthem, scroll to Helpful Links > Select Medical Policy and Prior Authorization for Blue Plans, then follow the prompts to determine the applicable home plan and prior authorization requirements. Submitting prior authorization requestsAvaility Essentials: - Log in to https://Availity.com.
- Select the Patient Registration tab to access Authorizations and Referrals.
- Select Authorization Request.
Note: Transplant prior authorization requests must be submitted by phone, fax, or secure email. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-081857-25-CPN81558 Anthem is happy to support the announcement of an exciting partnership between Premera Blue Cross, Amazon, and the American College of Lifestyle Medicine (ACLM) offering a free online Lifestyle Medicine & Food as Medicine Essentials Course for the entire provider community. In this comprehensive online course, you will explore the six pillars of lifestyle medicine, emphasizing how food and nutrition can play a critical role in preventing and treating chronic diseases. The course is tailor‑made for healthcare providers looking to enrich their care approach with practical evidence‑based strategies. This course is available until September 14, 2025. Benefits for providers:- Free access: Participate in this valuable training at no cost.
- Earn credits: Completing the course awards, you earn 5.5 CME/CE credits.
- Enhance your practice: Acquire tools to transform care and effectively address chronic disease.
How to enroll:- Visit https://lifestylemedicine.org/essentials.
- Log in or create an ACLM account.
- Enter promo code ESS‑AMZNEDU at checkout to access the course for free.
Contact us
Please reach out to Dr. Jon Liu at jonliu@amazon.com with questions regarding the free course. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-081296-25-CPN80998 Effective for dates of service on and after August 1, 2025, the following Clinical Criteria were developed and might result in services that were previously covered but may now be found to be not medically necessary.
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Document number
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Clinical Criteria
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CC‑0029
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Dupixent (dupilumab)
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CC‑0269
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Nemluvio (nemolizumab‑ilto)
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CC‑0122
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Arzerra (ofatumumab)
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CC‑0128
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Atezolizumab (Tecentriq, Tecentriq Hybreza)
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CC‑0158
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Enhertu (fam‑trastuzumab deruxtecan‑nxki)
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CC‑0121
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Gazyva (obinutuzumab)
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CC‑0061
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Gonadotropin Releasing Hormone Analogs for the Treatment of Non‑Oncologic Indications
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CC‑0125
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Opdivo (nivolumab)
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CC‑0008
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Subcutaneous Hormonal Implants
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CC‑0261
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Winrevair (sotatercept‑csrk)
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Access Clinical Criteria.
Our preapproval clinical review of non‑oncology specialty pharmacy drugs will be managed by our medical specialty drug review team. Drugs used for the treatment of Oncology will be managed by Carelon Medical Benefits Management, Inc. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. GABCBS-CM-080579-25 The Medical Policy and Technology Assessment Committee adopted new and/or revised Medical Policies and Clinical Guidelines that can be viewed in the attachment here. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. GABCBS-CM-080461-25 ATTACHMENTS (available on web): Georgia Medical Policy and Clinical Guideline update April 16, 2025 (pdf - 0.24mb) The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary. Please share this notice with other members of your practice and office staff. To view a guideline, visit the Medical Policies & Clinical UM Guidelines website. Medical Policies
The medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect May 25, 2025. Publish date | Medical Policy number | Medical Policy title | Status | 1/30/2025 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised | 1/30/2025 | DME.00053 | Home Video-Assisted Robotic Rehabilitation Systems | New | 1/30/2025 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions | Revised | 1/30/2025 | LAB.00037 | Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) | Revised | 1/30/2025 | MED.00151 | Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency | New | 1/30/2025 | MED.00152 | Outpatient Intravenous Insulin Therapy | New | 1/30/2025 | SURG.00165 | Histotripsy | New | 1/30/2025 | TRANS.00029 | Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias | Revised | 1/30/2025 | TRANS.00033 | Heart Transplantation | Revised |
Clinical UM Guidelines
The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect May 25, 2025. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | Status | 1/30/2025 | CG-DME-06 | Compression Devices for Lymphedema | Revised | 1/30/2025 | CG-MED-98 | Parenteral Antibiotics for the Treatment of Lyme Disease | Conversion New | 1/30/2025 | CG-OR-PR-04 | Cranial Remodeling Bands and Helmets (Cranial Orthoses)
Previously Titled: Cranial Remodeling Bands and Helmets (Cranial Orthotics) | Revised | 1/30/2025 | CG-RAD-26 | Maternity Ultrasound in the Outpatient Setting
Previous category and number: CG-MED-42 | Conversion New | 1/30/2025 | CG-SURG-123 | Autologous Fat Grafting and Injectable Soft Tissue Fillers | Conversion New | 1/30/2025 | CG-SURG-124 | Viscocanalostomy | Conversion New | 1/30/2025 | CG-SURG-125 | Canaloplasty | Conversion New | 1/30/2025 | CG-THER-RAD-07 | Intravascular Coronary and Non-Coronary Brachytherapy
Previously Titled: Intravascular Brachytherapy (Coronary and Non-Coronary) | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-082359-25-CPN81285 Effective for dates of service on and after August 1, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. These updates are part of the annual review process to promote clinically appropriate, safe, and affordable healthcare services. Genetic testingChromosomal microarray analysis: - Added neonatal death to the list of indications considered medically necessary.
- Added new section for Optical Genome Mapping (OGM) to clarify as not medically necessary.
Whole Exome Sequencing (WES) and Whole Genome Sequencing: - Clarified and restructured the criteria for improved readability.
- Added Medically Necessary criteria for Prenatal and PostNatal testing
- Added Not Medically Necessary statement for early neonatal death
- Added note that WES may include comparator testing.
Pharmacogenomic testing: - Deleted typo (“one” before “genotyping”) in first sentence
- Added “considered medically necessary for genotyping” to title of Table 1
- Added donanemab‑azbt for neurolytic genotyping for treatment of Alzheimer’s disease
- Added deuruxolitinib for dermatologic genotyping for treatment of alopecia areata
- Added NUDT15 risk allele for hematologic genotyping for thiopurine‑related myelosuppression risk in Asians and Hispanics
- Clarified therapeutic area for Eliglustat as related to hematology rather than pediatrics
Predictive and prognostic polygenic testing: - Updated Description/Scope and Rationale and added References
Musculoskeletal Interventional pain management: - Epidural and intradiscal injection procedures — renamed to include intradiscal injections; clarified requirement for contrast to confirm the needle placement; clarified language addressing when a second injection is indicated; reworded requirements related to advanced imaging.
- Diagnostic selective nerve root block (SNRB) — specified that imaging guidance with contrast to confirm needle position is required unless contraindicated; specified requirement for advanced imaging; clarified that post‑traumatic back pain contraindication applies only when the trauma is acute; added contraindication for cases where imaging studies have shown inadequate epidural space for needle placement at the target level.
- Exclusions:
- Added percutaneous intervertebral disc injection of allogeneic cellular and/or tissue‑based products to the exclusions section for epidural and intradiscal procedures and diagnostic selective root blocks.
- Excluded substances other than corticosteroids (with or without local anesthetic) in therapeutic SI joint injections.
- Intraosseous basivertebral nerve ablation — clarified that this procedure can be done in patients with Type I or Type II Modic changes on magnetic resonance imaging (MRI).
- Sacroiliac joint (SI) injections — clarified that confirmation of needle position must include contrast unless there is a documented allergy:
- Increased volume of injection to 2.5 cc, specified that a repeat SI joint injection is indicated when prior injection provided relief for at least 3 months
- Increased number of repeat therapeutic intraarticular SI joint injections in a 12‑month period from 3 to 4.
- Spinal cord stimulators — clarified that PDN refers to painful diabetic neuropathy:
- Specified nonsurgical low back pain as an exclusion.
As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management using the following: - Access the Carelon Medical Benefits Management provider portal directly at www.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.
For questions related to guidelines, please email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines on the Carelon Medical Benefits Management website by visiting guidelines.carelonmedicalbenefitsmanagement.com. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-078958-25-CPN78066 Effective June 1, 2025, the following Medicare Part B medication from the current Clinical Criteria Guidelines will be included in our medical step therapy preapproval review process. Step therapy review will apply upon preapproval initiation in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving the medication listed below. Visit our Clinical Criteria page to search for specific criteria. Clinical Criteria | Drug | Status | CC‑0166 | Hercessi (trastuzumab‑strf) | Non‑preferred |
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-077570-25-CPN77133 Effective for dates of service on and after August 1, 2025, the specialty Medicare Part B drug listed in the table below will be included in our preapproval review process. Federal and state law, state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over preapproval rules and must be considered first when determining coverage. Claims that do not comply with these new requirements may not be approved. HCPCS code | Medicare Part B drug | Q5136 | Jubbonti; Wyost (denosumab‑bbdz) |
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-077559-25-CPN77132 |