 Provider News IndianaDecember 2022 Anthem Provider News - IndianaSubmitting your updates in a timely manner helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form webpage for complete instructions.
Online update options include:
- Add/change an address location.
- Name change.
- Tax ID changes.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
Note that some updates may require additional documentation.
The Consolidated Appropriations Act (CAA), effective since January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Reimbursement changes to COVID-19 laboratory services codes for Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Indiana.
Beginning with dates of service on or after January 12, 2023, or the end of the public health emergency (PHE), whichever is the latter, reimbursement for COVID-19 laboratory services codes will be reduced for providers contracted as independent laboratory (ancillary) providers and participating in an Anthem independent laboratory provider network.
New COVID-19 laboratory service codes were implemented and reimbursed at rates to meet the needs of providers during the PHE. Reimbursement will be revised to Anthem’s standard reimbursement methodology for independent laboratory providers for the following codes:
|
U0001
|
86328
|
87426
|
87811
|
0226U
|
|
U0002
|
86408
|
87428
|
0202U
|
0240U
|
|
U0003
|
86409
|
87635
|
0223U
|
0241U
|
|
U0004
|
86413
|
87636
|
0224U
|
|
|
U0005
|
86769
|
87637
|
0225U
|
|
The revised standard fee schedule for the COVID-19 laboratory services codes outlined above can be viewed on www.availity.com* beginning January 12, 2023.
If you have any questions regarding this notice, please contact your designated Ancillary Provider Network manager. Please incorporate this notice into your Anthem provider agreement folder.
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research.
All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com > For Providers > Select Policies, Guidelines & Manuals under Provider Resources > scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.
We have provided many articles advising providers of the compliant messaging when our members call your office during an urgent situation after regular business hours.
The annual after-hours access studies performed by our vendor, North American Testing Organization* based in California, assesses adequate phone messaging for our members with perceived emergency or urgent situations after office hours. Unfortunately, most of the Anthem Blue Cross and Blue Shield (Anthem) plans assessed still fall short of the expectation of having a live person or a directive in place for after-hours calls.
Members are experiencing this lack of ability to reach instructions and have voiced their opinions in the member experience surveys fielded annually for Commercial and Marketplace Exchange. An average of 16% of members have a need to contact their provider’s office after regular hours for urgent care. They are recalling, in the last 12 months, if they were able to reach the office via an appropriate message, a transfer directly to their doctor or service for instructions, or advice.
This chart represents the office level accessibility when contacted by the survey vendor compared to the CAHPS® (Commercial) and EES© (Marketplace Exchange) member satisfaction survey results of the member’s success getting their urgent needs meet after hours.
As shown, the office level results are barely meeting or are below the expected 90% access to members with urgent symptoms. More telling is members express getting advice as soon as needed less often than the office assessment captures. A sizable number of members sometimes or never reach the doctor’s office for urgent instructions.
  To help both your patients’ and Anthem’s ability to reach your practice, we ask that you verify or update your office information using the online Provider Maintenance Form, and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.
- Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
- Be sure to turn on a messaging mechanism when you leave the office.
- Be sure you are using the acceptable messaging for compliance with your contract.
Per the provider manual, have your messaging or answering service include appropriate instructions, specifically:
- Emergency situations:
- A compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the emergency room (ER) or live person connects the caller directly to the practitioner.
- Urgent situations:
- Compliant responses for urgent needs after hours:
- Live person, via a service or hospital, advises their practitioner or on-call practitioner is available and connects.
- Live person or recording directs caller/patient to urgent care, ER or call 911:
- May also, but not instead of directing, suggest caller/patient contact their healthcare practitioner (via cell phone, pager, text, email, voicemail, etc.) or request a call back for further urgent instructions.
- Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)
- Non-compliant responses for urgent needs after hours:
- No provision for after-hours accessibility.
- Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions.
These scenarios are non-compliant because there is no direct connection to their practitioner, thus not ensuring a timely callback. This prompt can be used in addition to, but not in place of instructions.
Is your practice compliant?
The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.
It can be found on our website under the FAQ question about Laws and Rights that Protect You. To access, go to https://www.anthem.com and select For Providers. From there, select Policies, Guidelines & Manuals under Provider Resources. Select your state, and scroll down to Member Rights and Responsibilities under More Resources. Choose the Read about member rights link. Practitioners may access the FEP member website at www.fepblue.org/memberrights to view the FEPDO Members’ Rights and Responsibilities statement.
We have provided many articles advising of the compliant messaging when our members call your office during an urgent situation after regular business hours.
The annual after-hours access studies performed by our vendor, North American Testing Organization* based in California, assesses adequate phone messaging for our members with perceived emergency or urgent situations after office hours. Unfortunately, all Anthem Blue Cross and Blue Shield (Anthem) plans assessed still fall short of the expectation of having a live person or a directive in place for after-hours calls.
Well, the members are experiencing this lack of ability to reach instructions and have voiced their opinions in the member experience survey fielded annually for commercial and marketplace exchange via a behavioral health specific survey. An average of 29% of members have a need to contact their behavioral health practitioner after regular hours for urgent care. They are recalling, in the last 12 months, if they were able to reach the office for instructions, get a consultation they needed or get a timely call back?
This chart represents the office level accessibility when contacted by the survey vendor compared to the member satisfaction survey results of the member’s success getting their urgent needs meet after hours. As shown, the office level results are significantly below the expected 90% access to members with urgent symptoms.
Ironically, members express getting advice as soon as needed more often than the office assessment captures. Although a number of members sometimes, or never, reached the practitioner’s office for urgent instructions.
To help both your patients’ and Anthem’s ability to reach your practice, we ask that you verify or update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.
- Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
- Be sure to turn on a messaging mechanism when you leave the office.
- Be sure you are using the acceptable messaging for compliance with your contract.
Per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:
Emergency situations
Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the Emergency Room (ER) or live person connects the caller directly to the practitioner.
Emergent/Urgent situations
Compliant responses for urgent needs after hours:
- Live person or via a service, advises their practitioner or on call practitioner is available and connects.
- Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
- May also, but not instead of directing, suggest caller/patient may contact their BH care practitioner (via cell phone, pager, text, email, voicemail, etc.) or request a call back for further urgent instructions.
- Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)
- A live person or recording must express if there are prior arrangements with patients for after hour needs, to be compliant.
Non-compliant responses for urgent needs after hours:
- No provision for after hour accessibility.
- Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions.
These scenarios are non-compliant because there is no direct connection to their practitioner, thus not ensuring a timely callback. This prompt can be used in addition to, but not in place of instructions.
Is your practice compliant?
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment, and referral. Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other healthcare practitioners. This includes PCPs, medical specialists, and behavioral health practitioners.
Coordination of care is especially important for patients with high utilization of general medical services, and those referred to a behavioral health specialist by another healthcare practitioner. Anthem urges all its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other healthcare practitioners at the time treatment begins.
We expect all healthcare practitioners to:
- Discuss with the patient the importance of communicating with other treating practitioners.
- Obtain a signed release from the patient and file a copy in the medical record.
- Document in the medical record if the patient refuses to sign a release.
- Document in the medical record if you request a consultation.
- If you make a referral, transmit necessary information, and if you are furnishing a referral, report appropriate information back to the referring practitioner.
- Document evidence of clinical feedback (for example, consultation report) that includes, but is not limited to:
- Diagnosis.
- Treatment plan.
- Referrals.
- Psychopharmacological medication (as applicable).
In an effort to facilitate coordination of care, Anthem has several tools available on our provider website for behavioral health and other medical practitioners including:
- Coordination of Care Form.
- Coordination of Care Letter Template - Behavioral Health.
- Coordination of Care Letter Template - Medical.
The following behavioral health forms, brochures, and screening tools for substance use and attention-deficit/hyperactivity disorder (ADHD) are also available on our provider website:
- Alcohol Use Assessment
- Antidepressant medication management.
- Edinburgh Postnatal Depression Scale.
- Opioid Use Assessment brochure.
- Substance Brief Intervention/Referral Tool (SBIRT).
- Vanderbilt ADHD Diagnostic Parent Rating Scale.
Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.
Anthem Blue Cross and Blue Shield is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.
Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.
How do you contact us?
Anthem Blue Cross and Blue Shield (Anthem) utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Our medical policies are available on Anthem’s website at anthem.com.
You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. UM criteria are also available on the web. Just go to anthem.com, and select Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies and Clinical UM Guidelines.
We work with providers to answer questions about the utilization management process and the authorization of care. Here’s how the process works:
- Call us toll free from 8:30 a.m. to 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
- Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.
The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.
|
To discuss UM Process
and Authorization
|
To Discuss Peer-to-Peer
UM Denials w/Physician
|
To Request UM Criteria
|
TTY/TDD
|
Business Hours
|
|
Outpatient
800-345-4348
Inpatient
877-814-4803
Fax: 866-959-1395
Transplant
888-574-7215
Fax: 866-255-2471
National Transplant
844-644-8101
Fax: 888-438-7051
Behavioral Health
866-582-2293
Autism
Call customer service number on back of member’s ID card.
FEP
800-860-2156
Fax: 800 732-8318 (UM)
Fax: 877 606-3807 (ABD)
|
888-870-9342
National
800-821-1453
866-776-4793
Behavioral Health
866-582-2293
Adaptive Behavioral Treatment
Call customer service number on back of member’s ID card.
FEP
800-860-2156
|
877-814-4803
Behavioral Health
866-582-2293
FEP
800-860-2156
Fax: 800 732-8318 (UM)
Fax: 877 606-3807 (ABD)
|
711, or
TTY/Voice:
800-743-3333
|
Monday – Friday (except on holidays)
8:30 a.m. – 5 p.m.
More hours may be available in your area.
FEP
Monday – Friday
8 a.m. – 7 p.m. ET
|
For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.
Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.
This communication applies to the Medicaid program from Anthem Blue Cross and Blue Shield (Anthem) in Indiana.
Our pharmacy benefit management partner, IngenioRx,* will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.
This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.
If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:
- IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
- IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.
These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.
When e-prescribing orders to the mail and specialty pharmacies:
- Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
- If searching by NPI (National Provider Identifier), the NPI will not change.
In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.
Keeping you well informed is essential and remains our top priority. We will continue to provide updates prior to January and throughout 2023.
This communication applies to the Commercial, Medicaid, and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Indiana.
Anthem strives to ensure our providers understand documentation compliance, and we are committed to educating our providers in hopes of eliminating errors in documentation practices. It is a best practice and industry standard that physicians sign and date laboratory orders or requisitions.
Although the provider signature is not required on laboratory requisitions, if signed and dated, the requisition will serve as acceptable documentation of a physician order for the testing, and so it is strongly encouraged. In the absence of a signed requisition, documentation of your intent to order each laboratory test must be included in the patient’s medical record and available to Anthem upon request. Documentation must accurately describe the individual tests ordered; it is not sufficient to state “labs ordered.”
Anthem will consider laboratory order or requisition requirements met with one of the following:
- A signed order or requisition listing the specific test(s)
- An unsigned order or requisition listing the specific test(s), and an authenticated medical record supporting the physician’s intent to order the test(s)
- An authenticated medical record (for example, office notes or progress notes) supporting the physician’s intent to order the specific test(s)
Attestation statements are not acceptable for unsigned physician orders or requisitions. Signature stamps are not acceptable.
References:
This communication applies to all networks and programs from Anthem Blue Cross and Blue Shield (Anthem) in Indiana.
In April 2022, Anthem added new functionality for provider enrollment, the Digital Provider Enrollment (DPE) tool, hosted on Availity* to further automate and improve your online enrollment experience.
Effective December 1, 2022, we are no longer accepting the Provider Maintenance Form for enrolling newly contracted providers and adding providers to existing groups. Providers should use the Digital Provider Enrollment (DPE) tool for these functions.
Note that demographic changes and terminations should continue to be submitted using the Provider Maintenance Form at this link:
https://central.provider.anthem.com/mwpmf/entpmf/landingpage?brand=inabcbs
Who can use this new tool?
The Digital Provider Enrollment (DPE) tool is currently available for professional practitioners.
What features does the tool provide?
- Apply to add new practitioners to an already existing group
- Apply and request a contract to enroll a new group of practitioners
- Monitor submitted applications statuses real-time with a digital dashboard
How the online enrollment application works
The system pulls in all your professional and practice details from Council for Affordable Quality Healthcare (CAQH) ProView to populate the information Anthem needs to complete the enrollment process — including credentialing, claims, and directory administration. Please ensure your provider information on CAQH is updated and in complete or re-attested status.
The online enrollment application will guide you through the process, and a dashboard will display real-time application statuses. You’ll know where each provider is in the process without having to call or email for a status.
Accessing the provider enrollment application
Log onto availity.com and select Payer Spaces > Anthem > Applications > Provider Enrollment to begin the enrollment process.
Before you begin
If your organization is not currently registered for Availity, the person in your organization designated as the Availity administrator should go to availity.com and select Register.
For organizations already using Availity, your administrator(s) will automatically be granted access to the provider enrollment tool.
Staff using the provider enrollment tool need to be granted the user role Provider Enrollment by an administrator. To find yours, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.
Need assistance with registering for Availity?
Log onto availity.com/Contact-Us.
If you have any questions, please contact your Provider Experience Consultant.
*Change to Prior Authorization Requirements
Effective for dates of service on and after April 1, 2023, the following codes will require prior authorization through AIM Specialty Health.
|
CPT code
|
Description
|
|
81175
|
ASXL1 (additional sex combs like 1, transcriptional re.g.ulator) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence
|
|
81176
|
ASXL1 (additional sex combs like 1, transcriptional re.g.ulator) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (e.g., exon 12)
|
|
81206
|
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative
|
|
81207
|
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative
|
|
81208
|
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or quantitative
|
|
81218
|
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence
|
|
81233
|
BTK (Bruton's tyrosine kinase) (e.g., chronic lymphocytic leukemia) gene analysis, common variants (e.g., C481S, C481R, C481F)
|
|
81236
|
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence
|
|
81237
|
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (e.g., diffuse large B-cell lymphoma) gene analysis, common variant(s) (e.g., codon 646)
|
|
81273
|
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., mastocytosis), gene analysis, D816 variant(s)
|
|
81310
|
NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants
|
|
81315
|
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; common breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative
|
|
81316
|
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or quantitative
|
|
81320
|
PLCG2 (phospholipase C gamma 2) (e.g., chronic lymphocytic leukemia) gene analysis, common variants (e.g., R665W, S707F, L845F)
|
|
81334
|
RUNX1 (runt related transcription factor 1) (e.g., acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (e.g., exons 3-8)
|
|
81347
|
SF3B1 (splicing factor [3b] subunit B1) (e.g., myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (e.g., A672T, E622D, L833F, R625C, R625L)
|
|
81348
|
SRSF2 (serine and arginine-rich splicing factor 2) (e.g., myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (e.g., P95H, P95L)
|
|
81357
|
U2AF1 (U2 small nuclear RNA auxiliary factor 1) (e.g., myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (e.g., S34F, S34Y, Q157R, Q157P)
|
|
81360
|
ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (e.g., myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (e.g., E65fs, E122fs, R448fs)
|
|
0016U
|
Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation
|
|
0040U
|
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative
|
|
0049U
|
NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, quantitative
|
|
0101U
|
Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatous polyposis), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (15 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only])
|
|
0102U
|
Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencing and deletion/duplication])
|
|
0103U
|
Hereditary ovarian cancer (e.g., hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM [deletion/duplication only])
|
|
0306U
|
Gastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13C) spirulina substrate, analysis of each specimen by gas isotope ratio mass spectrometry, reported as rate of 13CO2 excretion
|
|
0307U
|
Clostridium difficile toxin(s) antigen detection by immunoassay technique, stool, qualitative, multiple-step method
|
|
0314U
|
Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 35 genes (32 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a cate.g.orical result (ie, benign, intermediate, malignant)
|
|
0315U
|
Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a cate.g.orical risk result (ie, Class 1, Class 2A, Class 2B)
|
|
0318U
|
Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood
|
|
0323U
|
Infectious agent detection by nucleic acid (DNA and RNA), central nervous system pathogen, metagenomic next-generation sequencing, cerebrospinal fluid (CSF), identification of pathogenic bacteria, viruses, parasites, or fungi
|
|
0326U
|
Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden
|
|
0329U
|
Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations
|
|
0331U
|
Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically significant alterations
|
|
S3852
|
DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease
|
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.
- You can also access AIM Specialty Health in some markets through www.Availity.com.
- Log onto www.Availity.com and select Authorizations and Referrals. Scroll down and select AIM Specialty Health. You will then be diverted to the AIM Specialty Health provider portal
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 http://www.aimspecialtyhealth.com/ClinicalGuidelines.html.
*Change to Prior Authorization Requirements
The following Medical Polices, and Clinical Guidelines for Anthem Blue Cross and Blue Shield (Anthem) were reviewed on August 11, 2022.
To view Medical Policies and Clinical Guidelines, go to www.anthem.com > select Providers > select your state > under Provider Resources, select Policies, Guidelines & Manuals.
To help determine if prior authorization is needed for Anthem members, go to www.anthem.com > select Providers > select your state > under Claims, select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card.
To view Medical Policies and Clinical Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® [FEP®]), please visit www.fepblue.org > Policies & Guidelines.
Below are the new medical policies and/or clinical guidelines that have been approved.
* Denotes prior authorization required
|
Policy/guideline
|
Information
|
Effective date
|
|
*MED.00140 Gene Therapy for Beta Thalassemia
|
- Outlines the MN and INV&NMN criteria for a one-time infusion of betibeglogene autotemcel for individuals with beta thalassemia
- No specific code for Zynteglo, listed NOC codes C9399, J3490, J3590 for the product, and ICD-10-PCS codes for transfusion of genetically modified stem cells to be reviewed for MN criteria; effective 10/01/2022 there will be specific ICD-10-PCS codes XW133B8, XW143B8 for transfusion of betibeglogene autotemcel
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03/01/2023
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DME.00049 External Upper Limb Stimulation for the Treatment of Tremors
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- Wrist-worn external upper limb tremor stimulator is considered INV&NMN for all indications, including but not limited to the treatment of essential tremor of the hands
- Existing HCPCS codes K1018, K1019 will be considered INV&NMN
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03/01/2023
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*DME.00050 Remote Devices for Intermittent Monitoring of Intraocular Pressure
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- The use of remote devices for intermittent monitoring of IOP is considered INV&NMN for all indications
- No specific code for this type of device, considered INV&NMN; listed E1399 NOC
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03/01/2023
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LAB.00049 Artificial Intelligence-Based Software for Prostate Cancer Detection
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- Use of artificial intelligence-based software for prostate cancer detection is considered INV&NMN for all indications
- No specific code for this product, considered INV&NMN; listed 88399 NOC
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03/01/2023
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MED.00141 High-volume Colonic Irrigation
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- High-volume colonic irrigation is considered INV&NMN for all indications
- Existing CPT Category 3 code 0736T (effective 07/1/2022) considered INV&NMN
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03/01/2023
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TRANS.00040 Hand Transplantation
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- Hand transplantation is considered INV&NMN
- No specific code CPT code, listed 26989 NOC; specific ICD-10-PCS proc codes 0XYJ0Z0, 0XYJ0Z1, 0XYK0Z0, 0XYK0Z1; considered INV&NMN
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03/01/2023
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Below are the current clinical guidelines and/or medical policies we reviewed, and updates were approved.
* Denotes prior authorization required
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Policy/guideline
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Information
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Effective date
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*CG-DME-31 Powered Wheeled Mobility Devices
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- Added HCPCS code E0986 for push-rim device, will be reviewed for MN criteria (was listed in CG-DME-34)
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03/01/2023
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In the October 2021, edition of the Provider News, Anthem Blue Cross and Blue Shield (Anthem) announced a new commercial policy titled Multiple Bilateral Surgery Processing - Facility effective for dates of service on or after January 1, 2022 . The policy indicated that Modifier 50 must be appended to facility claims when a bilateral procedure is performed. At this time, we have decided to remove this requirement for dates of service on or after January 1, 2022. Bilateral services should be billed as they were billed prior to January 1, 2022. The policy will be updated to remove the following:
- Modifier 50 must be appended to facility claims when a bilateral procedure is performed.
- When a surgical procedure code description contains the terminology bilateral or unilateral or bilateral or the code is considered inherently bilateral, modifiers LT, RT, or 50 should not be appended.
In addition, the policy title will be renamed to Multiple Surgery - Facility.
For specific policy details, visit the reimbursement policy page at anthem.com provider website.
*Change to Prior Authorization Requirements
Beginning with dates of service on or after March 1, 2023, Anthem Blue Cross and Blue Shield (Anthem) will update the Related Coding section of the Treatment Rooms with Office Evaluation and Management Services – Facility policy to include HCPCS code G0463. The code description for G0463 is hospital outpatient clinic visits or assessment and management of a patient. G0463 is not eligible for reimbursement when reported with revenue code 760, 761, or 769.
For specific policy details, visit the reimbursement policy page.
Effective January 1, 2023, Anthem Blue Cross and Blue Shield ’s (Anthem) Acupuncture Billed with Evaluation and Management – Professional policy will be retired. The policy aligns with standard correct coding requirements, as outlined in applicable CPT guidelines, which provide that Evaluation and Management services may be reported separately from acupuncture services by using modifier 25 when appropriate. Since the policy does not deviate from this guidance, the policy will be retired.
Anthem will enforce the requirements set forth in applicable CPT® guidelines. As always, Anthem reserves the right to request medical records when needed to validate appropriate billing.
For specific policy details, visit the reimbursement policy page.
*Change to Prior Authorization Requirements
Beginning with dates of service on or after March 1, 2023, Anthem Blue Cross and Blue Shield (Anthem) will update the Bundled Services and Supplies Policy - Professional to include two new CPT codes, 87913 and K1034, as not eligible for separate reimbursement. Specifically, Section 1 of the policy will be revised as follows to add these 2 new CPT codes:
The following codes are not eligible for reimbursement when they are reported with another service or reported as a stand-alone service:
- 87913 - Infectious agent genotype analysis by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), mutation identification in targeted region(s).
- K1034 - Provision of COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized, or cleared, one test count.
For specific policy details, visit the reimbursement policy page on anthem.com.
Anthem Blue Cross and Blue Shield is pleased to announce that we are expanding our member’s access to our Individual Marketplace plan, Pathway Essentials, in 2023.
Effective January 1, 2023, these new providers will be added to the Pathway Essentials network:
- Deaconess Health System is adding their hospitals and physicians located in southwest Indiana.
- Beacon Health is adding two new facilities in our northern Indiana area, Beacon Granger Hospital and Elkhart General Hospital.
This network has out-of-network coverage for emergency and urgent care services only.
Please watch our upcoming newsletter for an updated Pathway Essentials Quick Reference Guide for 2023.
Any questions? Please contact your Provider Relationship Account Manager.
Visit the Drug Lists page on anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes.
- Drug Lists and changes.
- Prior Authorization Criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The Commercial and Exchange Drug Lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate the Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
*Change to Prior Authorization Requirements
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Inclusion of a National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Step therapy updates:
Clinical Criteria ING-CC-0182 currently has a step therapy preferring Ferrlecit®, Infed®, and Venofer®.
Effective for dates of service on and after March 1, 2023, the status of Infed in current criteria documents will be changing in our existing specialty pharmacy medical step therapy review process. This update is to notify that Infed will change to non-preferred.
Also, effective for dates of service on or after December 1, 2022, Feraheme® (ferumoxytol) will change to preferred for both brand and generic.
Access our Clinical Criteria to view the complete information for these step therapy updates.
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Clinical Criteria
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Status
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Drug
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HCPCS or CPT® code(s)
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ING-CC-0182
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Nonpreferred
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Infed (iron dextran)
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J1750
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ING-CC-0182
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Nonpreferred
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Injectafer® (ferric carboxymaltose)
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J1439
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ING-CC-0182
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Nonpreferred
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Monoferric® (ferric derisomaltose)
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J1437
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ING-CC-0182
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Preferred
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Feraheme (ferumoxytol)
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Q0138
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ING-CC-0182
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Preferred
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Ferrlecit (sodium ferric gluconate/sucrose complex)
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J2916
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ING-CC-0182
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Preferred
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Venofer® (iron sucrose)
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J1756
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State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 1, 2022 Keep up with Medicaid News - December 2022State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 1, 2022 New Policy Diagnosis-Related Group Newborn Inpatient Stays - Facility(Policy G-17001, effective March 1, 2023)
Beginning with dates of services on or after March 1, 2023, Anthem Blue Cross and Blue Shield will implement a new facility reimbursement policy titled DRG Newborn Inpatient Stays. The policy indicates that when the reimbursement is based on the diagnosis related group (DRG), newborn inpatient stays should be billed with the appropriate revenue code to match the corresponding DRG code. If there is no Neonatal Intensive Care Unit (NICU) revenue code (0172, 0173, or 0174) listed on the claim, the claim will not group to a sick newborn DRG.
For additional information, please review the DRG Newborn Inpatient Stays reimbursement policy at https://providers.anthem.com/in.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 1, 2022 IngenioRx will become CarelonRx on January 1, 2023This communication applies to the Medicaid program from Anthem Blue Cross and Blue Shield (Anthem) in Indiana.
Our pharmacy benefit management partner, IngenioRx,* will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.
This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.
If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:
- IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
- IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.
These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.
When e-prescribing orders to the mail and specialty pharmacies:
- Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
- If searching by NPI (National Provider Identifier), the NPI will not change.
In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.
Keeping you well informed is essential and remains our top priority. We will continue to provide updates prior to January and throughout 2023.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 1, 2022 Monkeypox and smallpox vaccines: Product code on claimsBackground:
Providers are a trusted resource for patients when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.
Some providers may have seen a message on their provider Explanation of Payment (EOP) stating that Anthem Blue Cross and Blue Shield does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOP message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.
To aid in processing claims for the monkeypox and smallpox vaccine products, providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:
- Product code (90611 or 90622)
- Applicable ICD-10-CM diagnosis code
- Administration code
More detail on codes and cost-sharing
Providers are encouraged to use:
- Product code 90611 for smallpox and monkeypox vaccine.
- Product code 90622 for vaccinia (smallpox) virus vaccine.
- Code 87593 for laboratory testing.
When billing the monkeypox and smallpox vaccine products, providers should submit those codes with a $0.01 charge.
Cost-sharing for the vaccine and administration is waived.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your Provider Experience associate or refer to the Contact Us section at the bottom of our provider website (https://providers.anthem.com/in) for up-to-date contact information. You can read more information on monkeypox online.
Navigating the complexities and nuances associated with the COVID-19 pandemic requires frequent review of benefits and their impacts to our members’ social drivers of health. In recent evaluations, significant challenges have been identified by many agencies supporting our personal home helper benefit.
These nationwide impacts have led to many members unable to use the benefit to its fullest capacity. Therefore, effective January 1, 2023, the personal home helper benefit will no longer be offered within any of Anthem Blue Cross and Blue Shield’s (Anthem’s) Medicare individual plans. Members have been notified via their Annual Notice of Change. Improving the life of our members is Anthem’s focus and, while this change is difficult, Anthem will make best efforts to identify other resources for members or benefits to enhance their quality of life.
Please direct any member concerns or questions to the member services number on the back of their card.
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