• Medical Policy/Clinical Guidelines Updates – February 2019*

• Reimbursement Policy Updates – February 2019*

• Clinical criteria updates for specialty pharmacy*

• Specialty pharmacy prior authorization list expansion*

• Specialty pharmacy medical step therapy drug list expansion*

Other Important Updates

• Professional billing - Update regarding E/M with modifier 25

• Medicare and Medicaid updates

What’s new for 2019?

• The Controlling High Blood Pressure (CBP) measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
  
  
• If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
  
  
• Compliant BP is defined as <140/90 mm Hg for all members.
  
  
• Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the Provider can be utilized for the measure.

What do we need from you?

We need the last 2 office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018 please send that documentation as well.

Common chart deficiencies:

• Recheck elevated blood pressures readings and document all BP readings in the medical record.

For more information on HEDIS visit the Anthem Provider Portal online at Anthem.com. Click on Providers > Click Polices and Guidelines > Select your State>Scroll down and click View Med Policies and UM Guideline >Click Health & Wellness > Scroll down to Quality Improvement and Standards> and then scroll down on the page to HEDIS Information.

Thank you for your continued cooperation and support of HEDIS.

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

Anthem may offer additional benefits that are not covered under Original Medicare. Certain benefits are only covered when provided by a vendor selected by Anthem. More information can be found at anthem.com/medicareprovider. You may also contact Provider Services at the phone number on the back of the member ID card.

Additional information, including billing modifiers and documentation requirements, will be available at anthem.com/medicareprovider under Important Medicare Advantage Updates.

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

• 2019 risk adjustment provider training  
  
  
• New provider learning opportunity: Put the AIM ProviderPortal to work for you  
  
  
• New provider service phone number beginning January 1, 2019  
  
  
• Medicare Advantage reimbursement policy provider bulletin  
  
  
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective January 1, 2019  

Anthem Blue Cross and Blue Shield

Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

In the January issue of the Network Update, we incorrectly noted the effective date for the implementation of Facility Take-Home Drugs reimbursement policy. The effective date has been corrected.

Beginning on February 15, 2019, Anthem Blue Cross and Blue Shield does not allow reimbursement of take-home drugs — those dispensed by a facility for take-home use under the inpatient or outpatient hospital benefit. Claims submitted by a facility for drugs with revenue codes denoting take-home use will be denied.

www.anthem.com/inmedicaiddoc

^{Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.}

Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

Reimbursement Policy Update: Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

(Policy 06-003, effective 04/01/2019)

The Anthem Blue Cross and Blue Shield (Anthem) Modifier 25 reimbursement policy provides the criteria for reimbursement for a significant, separately identifiable evaluation and management (E&M) service performed by the same provider on the same day of the original service or procedure. Effective April 1, 2019, Anthem does not allow separate reimbursement for E&Ms performed on the same day as a major surgery (90-day global period).

For additional information, refer to the Modifier 25 reimbursement policy at www.anthem.com/inmedicaiddoc.

www.anthem.com/inmedicaiddoc

Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

While there’s no single, easy answer to the issue of health care disparities, the vision of My Diverse Patients is to harness the power of data and identify ways to bridge gaps often experienced by diverse populations.

We’ve heard it all our lives: in order to be fair, you should treat everybody the same. But the challenge is that everybody is not the same — and these differences can lead to critical disparities not only in how patients access health care, but in their outcomes as well.

The reality is that the burden of illness, premature death and disability disproportionately affects certain populations. My Diverse Patients features robust educational resources to help support you in addressing these disparities, such as:

• Continuing medical education about disparities, potential contributing factors and opportunities for you to enhance care.
  
  
• Real life stories about diverse patients and the unique challenges they face.
  
  
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

Accelerate your journey to becoming your patients’ trusted health care partner by visiting https://mydiversepatients.com today. You may also access the site with the QR code provided.

www.anthem.com/inmedicaiddoc

^{Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.}

Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

Effective for dates of service on and after May 1, 2019, the specialty pharmacy drugs and corresponding codes from current clinical criteria noted below will be included in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review (as is done currently).

The clinical criteria below have been updated to include the requirement of a preferred agent effective May 1, 2019.

The clinical criteria is publicly available on our provider website. Visit Clinical Criteria to search for specific clinical criteria.

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services:

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798

www.anthem.com/inmedicaiddoc

^{Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.}

Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

Anthem Blue Cross and Blue Shield (Anthem) is expanding their partnership with AIM Specialty Health® (AIM) for outpatient rehabilitative and habilitative services.

Effective March 1, 2019, AIM will provide health services review for prior authorization (PA) of physical therapy, occupational therapy and speech therapy for members enrolled in Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect.

This transition of utilization management services to AIM does not apply to the Franciscan Alliance Accountable Care Organization/St. Francis Health Network (or other delegated partners). Applied behavioral analysis (ABA) therapy remains covered for the treatment of autism spectrum disorder (ASD) for members 20 years of age and younger. ABA therapy services require PA, subject to the criteria outlined in Indiana Administrative Code 405 IAC 5-3. ABA requests will remain at the health plan. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services will also remain at the health plan.

As a reminder, outpatient therapy services currently require PA. Initial evaluations will not require PA, however, providers will be required to request authorizations for all services beginning with the first treatment visit.

AIM will continue to use Anthem clinical guidelines CG.REHAB.04, CG.REHAB.05, and CG.REHAB.06 for review of these services. The clinical guidelines can be reviewed on the Medical Policies and Clinical UM Guidelines Search tool located on the Anthem provider website at https://www11.anthem.com/search.html. You can also review them within Availity by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.

AIM peer-to-peer

If a peer-to-peer review is needed, AIM will contact the provider prior to rendering a denial. Three attempts will be made by AIM to complete the peer-to-peer review. If AIM is unsuccessful in reaching the provider, a denial decision will be rendered.

AIM reconsideration

AIM will accept reconsideration review requests via phone at 1-800-714-0040 or via the AIM portal up to 10 business days from the denial decision date. AIM will render the reconsideration decision and send the notification letter within seven business days.

Pre-service review requirements

Beginning February 11, 2019, providers will be able to contact AIM for prior authorization for services to take place on or after March 1, 2019. Providers are strongly encouraged to verify that a prior authorization has been obtained before scheduling and performing services.

Any authorizations approved through Anthem prior to March 1, 2019, will be honored and claims will process accordingly. For example, if a provider received an authorization for services starting on February 1, 2019, and the services will extend beyond March 1, 2019, the provider does not need to request a new authorization for services rendered after March 1, 2019.

How to place a review request

Providers can utilize the Prior Authorization Lookup Tool (PLUTO) located on the Anthem provider website at https://mediproviders.anthem.com/in/Pages/precertification-lookup.aspx to determine if a specific code requires prior authorization. PLUTO allows the user to search by CPT code, HCPCS code or code description.

Providers must utilize the AIM portal or call AIM directly to initiate a new request. The AIM ProviderPortalSM is available 24/7 except for scheduled maintenance and is the fastest, easiest way to contact AIM. The ProviderPortal offers a convenient way to enter your service requests or check the status of your previous services. Go to www.aimspecialtyhealth.com/goweb to begin. Registration is required and opens February 11, 2019.

To request prior authorization for outpatient therapy services, please follow this process:

• Log in to the AIM portal at https://providerportal.com or access the AIM portal via Availity at https://www.availity.com.
• Providers may contact AIM toll-free at 1-800-714-0040. Hours of operation are Monday through Friday from 8 a.m. to 8 p.m. Eastern time.
• Fax requests are not accepted for initial services reviewed by AIM.

While PA procedures for musculoskeletal services have changed as noted above, certain core services and capabilities — while subject to future changes, independent of AIM’s role in musculoskeletal services PA — remain unchanged at this time, including:

• Claims processing
• The network of providers offering these services to our members

Please note that adhering to these new policies and procedures is required to assure appropriate payment of claims. Should you have questions, please contact your local Network Relations representative. You may also contact Provider Services at the following numbers:

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798

For resources to help your practice get started with the Rehabilitation Program, go to www.aimprovider.com/rehabilitation.

www.anthem.com/inmedicaiddoc

^{Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.}

Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

If you have questions or feedback, please email us at druglist@anthem.com.

www.anthem.com/inmedicaiddoc

^{Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.}