 Provider News IndianaFebruary 2021 Anthem Provider News - Indiana Contents State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | February 1, 2021 Medicaid News - February 2021State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | February 1, 2021 Coding spotlight: HEDIS MY 2021
New prior authorization requirements for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.
Changes to Prior Authorization Requirements
- Prior authorization updates for specialty pharmacy are available – February 2021*
- Medical Policy and Clinical Guideline Updates – February 2021*
- Reimbursement policy update: Emergency Room Transfers – Facility*
- Reimbursement policy update: Treatment Rooms with Office Evaluation and Management Services – Facility*
Anthem will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the Provider Maintenance Form. Contact Provider Services if you have any questions.
Anthem Blue Cross and Blue Shield (Anthem) in Indiana includes fully insured or third party administrator (also known as self-insured) information on Commercial member ID cards.
If a member’s plan is fully insured, the language below will appear at the bottom of the back of the ID card.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association.
FULLY INSURED
If member’s plan is administered by a third party administrator (self-insured), the language below will appear at the bottom of the back of the ID card.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield provides administrative claims payment services only and does not assume any financial risk or obligation with respect to others.
As a reminder, electronic member ID cards are available on the Availity portal. When conducting an eligibility and benefits inquiry for Anthem members, select View Member ID Card on the Eligibility and Benefits results page. Images of both the front and back of the member ID card are available, allowing you to get this pertinent information.
Beginning in the first quarter of 2021, you will also be able to find this information in the message section below the Anthem logo on the member’s Eligibility and Benefits results page in the Availity portal.
In January we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.
In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:
- Medical Policies and Clinical Guidelines
- Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)
Steps to access the Authorization Lookup application through Availity Payer Spaces
Access to the tool does not require an Availity role assignment.
- Select Payer Spaces
- Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu
- Select the Applications tab
- Select the Authorization Rules Lookup tile
Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:
- Tax ID
- National Provider Identifier (NPI)
- Member ID and birth date
- Member’s Group number or Contract Code
(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)
- CPT/HCPCS code
Give this new tool a try and discover how much this will improve the efficiency of your authorization process.
Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal.
The following Anthem Blue Cross and Blue Shield medical polices will require prior authorization for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
NOTE *Precertification required
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Title
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Information
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Effective Date
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* GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
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• Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered Investigational and not medically necessary (INV&NMN) for all indications.
CPT PLA code 0203U (effective 10/01/2020) will be considered INV&NMN; also listed NOC codes 81479, 81599 considered NMN when specified as this test.
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5/1/2021
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* SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
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• Implantable peripheral nerve stimulation devices are considered INV&NMN for all indications including, but not limited to, treatment of acute and chronic pain
• Moved content addressing implantable devices (temporarily or permanently implanted) from DME.00011 to this new policy with no change in criteria.
Existing nonspecific codes 64555, 64575, 64590, C1767, C1778, C1787, L8679, L8680, L8683 for neurostimulator implantation and devices will be reviewed and considered INV&NMN for description of PNS systems for pain
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5/1/2021
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* CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
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This document addresses angiographic evaluation for dialysis access circuit dysfunction and treatment for stenotic or thrombosed arterio-venous grafts (AVG) or fistulas (AVF). This document does not address angiographic evaluation as a treatment for venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, or improving venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).
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5/1/2021
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A new facility reimbursement policy titled Emergency Room Transfers will be implemented beginning with dates of service on, or after May 1, 2021. The policy allows reimbursement for one emergency room visit when a patient is transferred between facilities operating under the same agreement, have the same tax identification number (TIN), or is under common ownership. The transferring facility will not be eligible for separate reimbursement.
For more information about this policy, view Anthem’s reimbursement policies online for your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
A new facility reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services will be implemented beginning with dates of service on, or after May 1, 2021. Anthem does not allow reimbursement for office evaluation and management services when reported on a CMS 1450 (UB-04) with revenue code 761 (treatment rooms). Modifiers will not override the edit.
For more information about this policy, view Anthem’s reimbursement policies online for your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
Effective with dates of service on and after April 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem will update its drug lists that support commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.
Prior authorization updates
Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Click here to access the Clinical Criteria information.
Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0183
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J3590
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Sogroya
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*ING-CC-0001
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J0886
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Injection, epoetin alfa (Procrit/Epogen)
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*ING-CC-0019
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J3489
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Reclast, Zometa
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* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Oncology use is managed by AIM.
Quantity Limit Updates
Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Click here to access the Clinical Criteria information.
Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0019
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J3489
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Reclast, Zometa
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Visit Pharmacy Information for Providers 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 drug list is posted to the web site quarterly (the first of the month for January, April, July and October).
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | February 1, 2021 Medicaid News - February 2021State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | February 1, 2021 Coding spotlight: HEDIS MY 2021HEDIS overview
The National Committee for Quality Assurance (NCQA) is a non-profit organization that accredits and certifies health care organizations. The NCQA establishes and maintains the Healthcare Effectiveness Data and Information Set (HEDIS®). HEDIS is a tool comprised of standardized performance measures used to compare managed care plans. The overall goal is to measure the value of healthcare based on compliance with HEDIS measures. HEDIS also allows stakeholders to evaluate physicians based on healthcare value rather than cost. This article will outline specific changes to the HEDIS measures as outlined by the NCQA. The changes are effective for the measurement year (MY) 2020 to 2021. It is important to note that the state health agency has the authority to determine which measures and rates managed care organizations should capture.
HEDIS data helps calculate national performance statistics and benchmarks and sets standards for measures in NCQA Accreditation.
Health plans use HEDIS performance results to:
- Evaluate the quality of care and services.
- Evaluate provider performance.
- Develop performance improvement initiatives.
- Perform outreach to providers and members.
- Compare performance with other health plans.
HEDIS MY 2020 new measures:
- Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)
- Pharmacotherapy for Opioid Use Disorder (POD)
- Breast Cancer Screening (BCS-E)
- Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
- Prenatal Depression Screening and Follow-Up (PND)
- Postpartum Depression Screening and Follow-Up (PDS)
HEDIS MY 2020 retired measures:
- Annual Monitoring for Patients on Persistent Medications (MPM)
- Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)
- Standardized Healthcare-Associated Infection Ratio (HAI)
Retired measures are no longer maintained by NCQA or included in the HEDIS measurement set. NCQA has determined that specific measures are clinically inappropriate and are no longer in use. Once retired, the measures are not used in any product, program or service, and all use must stop.
HEDIS MY 2020 revised hybrid measures:
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
- Childhood Immunization Status (CIS)
- Immunizations for Adolescents (IMA)
- Cervical Cancer Screening (CCS)
- Colorectal Cancer Screening (COL)
- Care for Older Adults (COA)
- Controlling High Blood Pressure (CBP)
- Medication Reconciliation Post-Discharge (MRP)
- Transitions of Care (TRC)
- Prenatal and Postpartum Care (PPC)
- Well-Child Visits in the First 15 Months of Life (W15)
- Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
- Adolescent Well-Care Visits (AWC)
HEDIS MY 2020 revised administrative measures:
- Appropriate Testing for Children with Pharyngitis (CWP)
- Statin Therapy for Patient’s with Cardiovascular Disease (SPC)
- Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)
- Osteoporosis Management in Women Who Had a Fracture (OMW)
- Follow-Up After Hospitalization for Mental Illness (FUH)
- Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
- Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
- Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
- Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)
HEDIS and telehealth
HEDIS measures include synchronous telehealth (which requires real-time interactive audio and video telecommunications), telephone visits and online assessments, as appropriate. A measure specification will indicate when telephone visits or online assessments are eligible for use in reporting.
A measure specification that is silent about telehealth is assumed to include telehealth. Correct coding requires billing telehealth services using standard CPT® and HCPCS codes for professional services in conjunction with a telehealth modifier and a telehealth POS code. Therefore, the CPT or HCPCS code in the value set will meet criteria (regardless of whether a telehealth modifier or POS code is present). A measure specification will indicate when telehealth is not eligible for use and is excluded.
The future of HEDIS
The future of HEDIS focuses on six core ideas:
- Allowable adjustments: New flexibility lets users modify measures without changing their clinical intent.
- Licensing and certification: Updated requirements ensure the accuracy of the results.
- Digital measures: HEDIS specifications that download directly into users’ data systems bring new ease of use.
- Electronic clinical data systems (ECDS): This new reporting method helps clinical data create insight for managing the health of individuals and groups.
- Schedule change: A new schedule gives users more time by providing the complete measure specifications sooner – 11 months earlier than the traditional timeline.
- Telehealth: The access to care that telehealth has brought during COVID-19 is vital to quality now after the pandemic.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Resources
HEDIS® Measures and Technical Resources. https://www.ncqa.org/HEDIS®/measures On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC (AMH Health). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).
Effective December 1, 2020, Anthem will transition the Clinical Criteria for medical necessity review of CGSURG-74 Total Ankle Replacement services to AIM Specialty Health®* small joint guidelines. Click here for more information about the transition to AIM small joint guidelines.
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