 Provider News GeorgiaNovember 2019 GA Provider NewsSavannah Town Hall
November 07, 2019
1:00 p.m.–3:00 p.m. Light refreshments provided
Georgia Southern University
Nessmith-Lane Conference Center
847 Plant Drive
Statesboro, GA 30458
Please R.S.V.P. by Monday, November 4th to RSVPBlue@anthem.com. Include the name of the facility or practice, and the number of attendees.
Atlanta Town Hall
November 19, 2019
1:00 p.m.–3:00 p.m. Light refreshments provided
Wellstar
Atlantic Auditorium
2000 South Park Place
Atlanta, Ga 30339
Please R.S.V.P. by Thursday, November 14th to RSVPBlue@anthem.com. Include the name of the facility or practice, and the number of attendees.
Town Hall updates will include:
- Availity
- Network updates
- State Health Benefit Plan (SHBP)
- AIM Specialty programs
- Provider services contact information
- Medicare
More exciting new changes are coming to the public provider site at anthem.com. This next wave of updates includes a new, enhanced Medical Policies page. The page will have an improved and straightforward process for viewing policies that allows providers to easily scan, sort and filter. In addition, providers will now be able to access “Search” from the Medical Policies landing page. Below is a preview of the streamlined page:
As the physician of a member who has coverage under Affordable Care Act (ACA) compliant plans, you play a vital role in accurately documenting the health of the member to ensure compliance with ACA program reporting requirements. When members visit your practice, we encourage you to document ALL of the members’ health conditions, especially chronic diseases. Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.
Please ensure that all codes captured in your EMR system are also included on the claim(s), and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing 4. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.
Reminder about ICD-10 coding
As you may be aware, the ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends and costs, disease management, and clinical effectiveness of management of medical conditions. The Centers for Medicare and Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a member’s health.
Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.
- Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
- Include any secondary diagnosis codes that are actively being managed.
- Include all chronic historical codes, as they must be documented each year pursuant to the ACA. (E.g.: An amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).
If you are interested in having a coding training session conducted by an Anthem coding auditor, please contact the Georgia Commercial Risk Adjustment Representative Alicia Estrada at Alicia.Estrada@anthem.com.
Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Advanced Imaging of the Abdomen and Pelvis Clinical Appropriateness Guidelines.
- Foreign body (Pediatric only), Gastrointestinal bleeding, Henoch-Schonlein purpura, Hematoma or hemorrhage – intracranial or extracranial, Perianal fistula/abscess (fistula in ano), Ascites, Biliary tract dilatation or obstruction , Cholecystitis, Choledocholithiasis, Focal liver lesion, Hepatomegaly, Jaundice, Azotemia, Adrenal mass, indeterminate, Hematuria, Renal mass, Urinary tract calculi, Adrenal hemorrhage, Adrenal mass, Lymphadenopathy, Splenic hematoma, Undescended testicle (cryptorchidism)
- Abdominal and/or pelvic pain
- Combined pelvic pain with abdominal pain criteria in new “abdominal and/or pelvic pain” indication
- Required ultrasound or colonoscopy for select adult patients based on clinical scenario
- Ultrasound-first approach for pediatric abdominal and pelvic pain
- Lower extremity edema
- Added requirement to exclude DVT prior to abdominopelvic imaging
- Splenic mass, benign, Splenic mass, indeterminate, Splenomegaly
- Added new indications for diagnosis, management, and surveillance of splenic incidentalomas following the ACR White Paper (previously reviewed against “tumor, not otherwise specified”)
- Pancreatic mass
- Separated criteria for solid and cystic pancreatic masses
- Defined follow up intervals for cystic pancreatic masses
- Diffuse liver disease
- Added criteria for MR elastography
- Inflammatory bowel disease
- Limited requirement for upper endoscopy to patients with relevant symptoms
- New requirement for fecal calprotectin or CRP to differentiate IBS from IBD
- Enteritis or colitis, not otherwise specified
- Incorporated Intussusception (pediatric only), and Ischemic bowel
- Prostate cancer
- Moved this indication to Oncologic Imaging Guideline
- CPT codes
- Added MR elastography CPT code 76391
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.
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 on the AIM website. Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Radiation Therapy Clinical Appropriateness Guidelines.
- Special Treatment Procedure and Special Physics Consult
- Removed oral cone endocavitary indication
- Intensity Modulated Radiation Therapy (IMRT), Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT) for bone metastases
- Broadened description of adjacent normal tissues which may be of concern.
- Single fraction treatment
- Removed poor performance status criteria
- Central Nervous System cancers
- Spine Lesions; Primary or Metastatic Lesions of the Spine, Metastatic Lesions in the Lung
- Added note calling out separate criteria for curative intent treatment of extracranial oligometastatic disease.
- SBRT in the treatment of extracranial oligometastatic disease
- Added new section with discussion and indications
- Prostate cancer – hypofractionation
- Added fractionation guideline with EBRT/IMRT.
- Prostate cancer – postoperative radiotherapy and SBRT
- Added indication based on ASTRO/ASCO/AUA recommendation
- Prostate cancer – use of hydrogel spacer
- Added discussion and medical necessity statement about hydrogel spacers for prostate irradiation
- CPT code changes
- Added 77316, 77295 and 55874
- Removed 77427
As a reminder, ordering and servincing 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 on the AIM website.
Please note, this program does not apply to FEP or National Accounts Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Musculoskeletal Program Spine Surgery Clinical Appropriateness Guidelines.
- Conservative management – all sections
- Addition of physical therapy or home therapy requirement and one complementary modality for all spine procedures based on preponderance of benefit over harm to conservative care
- Lumbar Disc Arthroplasty
- Changed the duration of conservative management from 1 year to 6 months based on the FDA prospective study that was done to approve the lumbar disc arthroplasty procedure
- Added age, level requirements, and symptom/sign requirement and clarified contraindications in reflect these changes
- Added exclusions criteria of Prior spine surgery of any form at the target level
- Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
- Inclusion for implant failure similar to cervical spine
- Consolidated juvenile and congenital in adolescent idiopathic
- Decreased duration of conservative management required based on lower evidence for efficacy in spinal stenosis and specialty panel feedback
- Excluded anterior lumbar interbody fusion for foraminal stenosis without evidence of instability exclusion due to very low quality evidence for efficacy
- Lumbar Laminectomy
- Decreased duration of conservative care required for known spinal stenosis based on guidance from NASS and less evidence for efficacy of conservative management in this population
- Aligned conservative care duration with discectomy criteria
- Added new indication for synovial cyst
- Noninvasive Electrical Bone Growth Stimulation
- Clarification of guideline intent
- Allow active nicotine use as a risk factor in lumbar uses of bone growth stimulation
- Allow thoracic fusion similar to lumbar
- Bone Graft Substitutes and Bone Morphogenetic Proteins
- Allow active nicotine use as a risk factor for pseudoarthrosis in graft failure
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 on the AIM website. Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guidelines.
- Polysomnography and Home Sleep Testing: Established sleep disorder (OSA or other) – follow-up laboratory studies
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
- Management of OSA using APAP and CPAP Devices
- Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
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 on the AIM website. Open the attached document titled “GA preapproval list change notification 11.1.2019” to view the new and/or revised Medical Policies and Clinical Guidelines adopted by the Medical Policy and Technology Assessment Committee.
Open the attached document titled “ GA medical policy and clinical guideline updates 11.1.2019” to view the new and/or revised Medical Policies and Clinical Guidelines adopted by the Medical Policy and Technology Assessment Committee. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Anthem and all the Medical Policies are available at anthem.com/provider under “see policies and guidelines”. Please note that our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday through Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to:
Anthem Blue Cross and Blue Shield
Attention: Prior Approval, Mail Code GAG009-0002
3350 Peachtree Road NE
Atlanta, GA 30326
NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes. As we communicated in the October 2019 edition of Provider News, the AIM Rehabilitative program for our Commercial membership will relaunch on November 1. AIM Specialty Health® (AIM), a separate company, will begin to perform prior authorization review of physical, occupational and speech therapy services. Prior authorization requests may be submitted via the AIM ProviderPortalSM for dates of service on or after November 1, 2019. The OrthoNet program is no longer active in applicable markets.
Anthem is also transitioning vendors for review of outpatient physical, occupational and speech therapy rehabilitative services for our Medicare members to AIM Specialty Health. We have decided to delay the implementation of this transition. The AIM Rehabilitative program for Medicare members will now begin in April 2020. Prior authorization will not be required for the above-mentioned services for Medicare members through March 2020. (Note: This delay does NOT apply to members in the states of Florida, New Jersey and New York for whom prior authorization will still be required.) We will provide an update in an upcoming Provider News about the AIM Rehabilitative Program for Medicare members. This article was corrected on November 6, 2019. The original article incorrectly stated that the AIM Musculoskeletal Program would begin on November 1, 2019. The correct date that the AIM Musculoskeletal Program will begin is December 1, 2019. Anthem Blue Cross and Blue Shield (“Anthem”) announced in March 2018 that the AIM Musculoskeletal Program was delayed. AIM Specialty Health® (AIM), a separate company, will perform prior authorization reviews of certain surgeries of the spine and joints, as well as interventional pain treatment to determine medical necessity for Commercial fully insured Anthem members beginning December 1, 2019 for dates of service on and after December 1, 2019.
The new musculoskeletal program includes review of the level of care/setting, pre-operative days, and expected length of stay for medical necessity using AIM clinical guidelines which have been adopted by Anthem. All codes and clinical guidelines included in the musculoskeletal program can be found on the AIM MSK website.
The AIM ProviderPortalSM will be available for prior authorization order request submissions twenty-four hours a day, seven days a week, processing requests in real-time using clinical criteria. Providers may also submit request via the AIM Call Center by calling 866-714-1103 Monday through Friday 8:30 a.m.–8:00 p.m. Prior authorization updates
Effective for dates of service on and after February 1, 2020, 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 NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
To access the clinical criteria document information please visit our provider website.
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.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0072
|
Q5118
|
Zirabev
|
|
ING-CC-0075
|
Q5115
|
Truxima
|
|
ING-CC-0075
|
J3490
|
Ruxience
|
|
ING-CC-0107
|
Q5118
|
Zirabev
|
|
*ING-CC-0142
|
J1930
|
Somatuline Depot
|
|
ING-CC-0143
|
C9399
J9999
|
Polivy
|
|
ING-CC-0144
|
J9313
|
Lumoxiti
|
|
ING-CC-0145
|
J9119
|
Libtayo
|
Clinical criteria updates
Effective for dates of service on and after February 1, 2020, the following current clinical criteria documents were revised and might result in services that were previously covered but may now be found to be not medically necessary.
To access the clinical criteria document information please visit our provider website.
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-0001 Erythropoiesis Stimulating Agents: Reduced the timeframe for response for the use of Aranesp, Epogen and Procrit for anemia associated with myelosuppressive chemotherapy from 8-9 weeks to 8 weeks.
- ING-CC-0002 Colony Stimulating Factor Agents: Removed medically necessary criteria for the prophylaxis of febrile neutropenia for Leukine.
- ING-CC-0041 Complement Inhibitors: Added medical necessity criteria for Soliris for the new indication of neuromyelitis optica spectrum disorder.
- ING-CC-0048 Spinraza (nusinersen): Updated medical necessity criteria for use after gene therapy to require decline in clinical status.
- ING-CC-0082 Onpattro (patisiran): Added not medically necessary criteria for combination use with other agents for amyloidosis.
- ING-CC-0106 Erbitux (cetuximab): Updated medical necessity criteria for RAS testing to require both KRAS and NRAS wild type.
Quantity limit updates
Effective January 31, 2020, clinical criteria document ING-CC-0136 Drug dosage, frequency, and route of administration will be archived.
Effective for dates of service on and after February 1, 2020, prior authorization clinical review of drug dosage, frequency and route of administration for the following specialty pharmacy codes from new or current clinical criteria will be based on the quantity limits established in the applicable clinical criteria document. The table below will assist you in identifying the applicable clinical criteria documents and corresponding HCPCS codes.
To access the clinical criteria document information please visit our provider website.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.
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Clinical Criteria Document Number
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS Code(s)
|
|
ING-CC-0001
|
Erythropoiesis Stimulating Agents
|
Aranesp, Epogen, Mircera, Procrit, Retacrit
|
J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106
|
|
ING-CC-0003
|
Immunoglobulins
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Asceniv, Bivigam, Carimune NF, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen
|
J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
|
|
ING-CC-0007
|
Synagis (palivizumab)
|
Synagis
|
90378
|
|
ING-CC-0013
|
Mepsevii (vestronidase alfa)
|
Mepsevii
|
J3397
|
|
ING-CC-0018
|
Lumizyme (alglucosidase alfa)
|
Lumizyme
|
J0221
|
|
ING-CC-0021
|
Fabrazyme (agalsidase beta)
|
Fabrazyme
|
J0180
|
|
ING-CC-0022
|
Vimizim (elosulfase alfa)
|
Vimizim
|
J1322
|
|
ING-CC-0023
|
Naglazyme (galsulfase)
|
Naglazyme
|
J1458
|
|
ING-CC-0024
|
Elaprase (idursufase)
|
Elaprase
|
J1743
|
|
ING-CC-0025
|
Aldurazyme (laronidase)
|
Aldurazyme
|
J1931
|
|
ING-CC-0028
|
Benlysta (belimumab)
|
Benlysta
|
J0490
|
|
ING-CC-0031
|
Intravitreal Corticosteroid Implants
|
Illuvien, Retisert, Ozurdex, Yutiq
|
J7311, J7312, J7313, J7314
|
|
ING-CC-0032
|
Botulinum Toxin
|
Botox, Xeomin, Dysport, Myobloc
|
J0585, J0586, J0587, J0588
|
|
ING-CC-0033
|
Xolair (omalizumab)
|
Xolair
|
J2357
|
|
ING-CC-0034
|
Agents for Hereditary Angioedema
|
Cinryze, Haegarda, Berinert, Berinert, Firazyr, Ruconest, Kalbitor, Takhzyro
|
J0596, J0597, J0598, J1290, J1744, J0599, J0593
|
|
ING-CC-0041
|
Complement Inhibitors
|
Soliris, Ultomiris
|
J1300, J1303
|
|
ING-CC-0043
|
Monoclonal Antibodies to Interleukin-5
|
Cinqair, Fasenra, Nucala
|
J0517, J2182, J2786
|
|
ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
Tremfya, Ilumya
|
J1628, J3245
|
|
ING-CC-0051
|
Enzyme Replacement Therapy for Gaucher Disease
|
Cerezyme, Elelyso, Vpriv
|
J1786, J3060, J3385
|
|
ING-CC-0058
|
Octreotide Agents
|
Sandostatin, Sandostatin LAR Depot
|
J2353, J2354
|
|
ING-CC-0061
|
GnRH Analogs for the treatment of non-oncologic indications
|
Lupron Depot/Depot-Ped
|
J1950, J9217
|
|
ING-CC-0062
|
Tumor Necrosis Factor Antagonists
|
Simponi Aria, Remicade, Inflectra, Renflexis, Ixifi, Humira, Enbrel, Cimzia
|
J1602, J1745, Q5103, Q5104, Q5109, J0135, J1438, J0717
|
|
ING-CC-0063
|
Stelara (ustekinumab)
|
Stelara
|
J3357, J3358
|
|
ING-CC-0066
|
Monoclonal Antibodies to Interleukin-6
|
Actemra
|
J3262
|
|
ING-CC-0071
|
Entyvio (vedolizumab)
|
Entyvio
|
J3380
|
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Avastin, Lucentis, Eylea, Macugen, Zirabev, Mvasi
|
J2503, C9257, J9035, J2778, J0178, Q5118, Q5017
|
|
ING-CC-0073
|
Alpha-1 Proteinase Inhibitor Therapy
|
Aralast, Glassia, Prolastin-C, Zemaira
|
J0256, J0257
|
|
ING-CC-0075
|
Rituxan (rituximab) for Non-Oncologic Indications
|
Rituxan, Truxima
|
J9312, Q5115
|
Anthem’s launch of our new pharmacy benefits manager (PBM) solution, IngenioRx, is nearly complete. IngenioRx serves members of all Anthem-affiliated health plans. We began transitioning members on May 1, 2019, and have continued throughout 2019, with all members completely transitioned to IngenioRx by January 1, 2020.
As a reminder, most day-to-day pharmacy experiences will not be affected:
- Members will continue to use their prescription drug benefits as they always have, getting their medications using a retail pharmacy, home delivery, or specialty pharmacy.
- Current home delivery and specialty pharmacy prescriptions and prior authorizations will transfer automatically to IngenioRx when a member transitions, with the exception of controlled substances and compound drugs (see more below).
- If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx after your patient has transitioned.
- If you do not use ePrescribing, send home delivery and specialty pharmacy prescriptions to IngenioRx after your patient has transitioned (see contact information below).
- Members will continue to use the same drug list.
- Prior authorizations will automatically transfer to IngenioRx.
Frequently Asked Questions
When can I expect my patients to transition to IngenioRx?
Most Anthem members have already transitioned to IngenioRx. The remaining members will be transitioned on January 1, 2020.
Do providers need to take any action?
Federal law does not allow prescriptions for controlled substances or compound drugs to be automatically transferred to another pharmacy, so providers with patients using these medications will need to send a new prescription to IngenioRx after they’ve transitioned.
Will my patients be notified of this change?
Anthem will notify members before they transition to IngenioRx. Members currently filling home delivery and specialty pharmacy medications will be notified by mail.
How will a provider know if an Anthem member has moved to IngenioRx?Availity displays member PBM information under the patient information section as part of the eligibility and benefits inquiry. We have enhanced this section of Availity to indicate when a member has moved to IngenioRx. Availity includes the name of the PBM and date the member moved to IngenioRx, or the date the member is scheduled to move to IngenioRx.
How will specialty drugs be transitioned? Specialty pharmacy prescriptions and prior authorizations will automatically transfer to IngenioRx. In addition, the IngenioRx Care Team will call members to introduce them to IngenioRx and discuss the medications they take.
How do I submit prescriptions to IngenioRx?If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx in your ePrescribing system.
If you do not use ePrescribing, you can submit prescriptions using the following information:
IngenioRx Home Delivery Pharmacy new prescriptions:
Phone Number: 1-833-203-1742
Fax number: 1-800-378-0323
IngenioRx Specialty Pharmacy:
Prescriber phone: 1-833-262-1726
Prescriber fax: 1-833-263-2871
What phone number should I call with questions?For questions, contact the Provider Service phone number on the back of your patient’s ID card. Medicare Advantage
The Blue Cross and Blue Shield Association issued a mandate requiring a change in the way we process Host and Home plan HEDIS® STARS Care Gaps, risk adjustment (RADV) and medical records requests. The goal of this mandate is to improve health outcomes and care management for Medicare Advantage out-of-area members.
More information about this mandate will be published in the December 2019 newsletter.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Medicare Advantage
CMS defines an expedited/urgent request as ‘an expedited/urgent request for a determination is a request in which waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in seriously jeopardy.’ Contracted providers should submit requests in accordance with CMS guidelines to allow for organization determinations within the standard turnaround time, unless the member urgently needs care based on the CMS definition of an expedited/urgent request. |