As a reminder, Anthem Blue Cross and Blue Shield (Anthem) will update our claim editing software monthly for outpatient facility services throughout 2021 with the majority of maintenance updates occurring quarterly in 2021.

 

These updates will:

• Reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers, Revenue Codes) and their associated edits
• Include appropriate use of various code combinations, which can include, but are not limited to, procedure code to revenue code, HCPCS to revenue code, type of bill to procedure code, type of bill to HCPCS code, procedure code to modifier, and HCPCS to modifier
• Include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Include updates to reflect coding requirements as designated by industry standard sources such as The National Uniform Billing Committee (NUBC)

 

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The Indiana Workers’ Compensation Network Leasing List has been updated with the names of the workers’ compensation payers and employer groups affiliated with First MCO.

 

If you provide treatment to an injured worker from a workers’ compensation payer or employer group affiliated with First MCO, your reimbursement will be based on the Anthem Workers’ Compensation rate.

 

This updated Anthem Workers’ Compensation Network Leasing List is available on the Availity Web Portal at availity.com.

 

For questions regarding your Anthem Workers’ Compensation Participation Attachment or Agreement, or other Workers’ Compensation issues, please call 866-700-2168.

 

For questions regarding your Anthem Workers’ Compensation reimbursement rate, please call 855-766-3719.

 

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Volunteers Needed: Join the Hunger Challenge in Kentuckiana

 

The Anthem Foundation and Dare to Care Food Bank are teaming up to fill a growing gap in volunteers and dollars needed to feed those facing food insecurity in Kentuckiana. Hunger and food insecurity are reaching staggering heights in the wake of COVID-19, leaving one in seven people in Kentuckiana worried about having enough food to put on the table. We invite you, your office staff, and patients to join the challenge.

 

The Dollars for Doers Challenge covers the entire 13-county region. Anthem Foundation will donate $10 for every hour volunteered at Dare to Care through February 12. A family of four can generate $120 in matching funds through a three-hour volunteer shift.

 

Visit Volunteer.DaretoCare.org or call 502-966-3821 to volunteer now through February 12, 2021.

 

As part of our commitment to build healthier lives and communities, the Anthem Foundation will automatically match every hour volunteered with a $10 donation to Dare to Care. Please cascade this message to anyone who may be interested in volunteering.

 

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Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized survey conducted between February to May each year to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may receive the survey. Over half of the questions used for scoring are directly impacted by providers.

 

The survey questions are:

• When you needed care right way, how often did you get it?
• How often did you get an appointment for a check-up or routine care as soon as you needed?
• How often was it easy to get the care, tests, or treatment you needed?
• How often did you get an appointment to see a specialist as soon as you needed?
• How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
• How would you rate your personal doctor?
• How would you rate the specialist you see most often?

To learn more about how you can improve the patient experience review What Matters Most: Improving the Patient Experience, an online course for providers and office staff. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at www.patientexptraining.com.

 

Your efforts to create an exceptional care experience for your patients will help to strengthen their healthcare journey.

 

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Anthem Blue Cross and Blue Shield (Anthem) recognizes all coding changes from both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) effective the date provided by the coding source. This includes the Evaluation and Management (E/M) changes effective January 1, 2021.

 

The following updates pertaining to Evaluation and Management services have been identified:

• CPT code 99201 (new patient E/M) will be a deleted code.
• CPT codes 99202 through 99215 (new/established E/M) definitions have changed. Selection of these E/M codes can now be based on either Medical Decision Making or Time.
• CPT code 99417 (prolonged services) and HCPCS Code G2212 (prolonged services) will be recognized as billable codes. These codes will be payable based on our existing Prolonged Services policy, which will be updated to reflect the new code along with the modifications to existing prolonged service codes CPT codes 99354 and 99355.
• HCPCS Code G2211 (complexity inherent to evaluation and management associated with primary medical care) will not be separately reimbursed for this service.  We will be updating our Bundled Services and Supplies policy to reflect this position.

 

Additionally, we are in the process of updating reimbursement policies impacted by the E/M service changes such as the Documentation and Reporting Guidelines for Evaluation and Management Services. 

 

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New health plans built around Anthem Blue Cross and Blue Shield (Anthem)’s Blue High Performance Network will take effect January 1, 2021.

 

Blue HPN^® plans offer access to providers with a record of delivering high-quality, efficient care. Blue HPN networks will go live January 1, 2021 in more than 50 cities across the country, including in the Indianapolis, South Bend, Fort Wayne and Evansville metro areas.

 

Blue HPN is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue HPN network.

 

In Indiana, Anthem is offering large and small group employers plans with access to the Blue HPN network, with the existing HealthSync network as the Indiana HPN entry. The entire HealthSync service area will be in-network for members of plans with HPN access.

 

If you are not sure whether your practice is part of the Blue HPN/HealthSync network, ask your office manager or business office, or contact your Anthem Provider Relations Representative. Blue HPN participation will be displayed in provider profiles in our online provider directory. Please search our provider finder tool on anthem.com for participation in the HealthSync Network as Blue HPN uses this existing network in Indiana.

 

Beginning January 1, you may see patients accessing the Blue HPN/Blue Preferred Network through new products. These will be HMO or HSA plans with an HMO network. Under these plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.

 

Large group Blue HPN health plans sold in Indiana will have a plan prefix of H8I; small group plans sold in Indiana will have a prefix of H9I, and MEWA plans sold in Indiana will have a prefix of H6I.  Keep in mind that other prefixes may be part of HPN plan member IDs. The sample ID card below is for a fictional member from Indiana  enrolled in a plan with an “H9I” prefix. The new “Blue High Performance Network” logo and “HPN” indicator in the suitcase icon are the most reliable indicators that a member is enrolled in an HPN plan.

 

Questions? Please reach out to your dedicated Anthem of Indiana network consultant.

 

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New prior authorization requirements for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements and are starred (*) below.

• Designated specialty pharmacy network*
• Prior authorization updates for specialty pharmacy are available – January 2021*
• Medical Policy and Clinical Guideline Updates – January 2021*
• MCG Care Guidelines 24th Edition Customization*
• Reimbursement policy update: Multiple diagnostic imaging procedures – Professional*
• Reimbursement policy update: Frequency Editing – Professional*
• Reimbursement policy update: Guidelines for Reporting Timed Units for Physical Medicine and Rehabilitation – Professional*
• Reimbursement policy update: Modifier Rules – Professional*
• Reimbursement policy update: Unit Frequency Maximum for Drugs and Biologicals – Professional*

Other important updates:

• Evaluation and management changes 2021
• Anthem implements pilot program for in-network skilled nursing facilities (SNF)

As a reminder, Anthem Blue Cross and Blue Shield (Anthem) will update our claim editing software monthly for professional services throughout 2021 with the majority of maintenance updates occurring quarterly in February, May, August and November of 2021.

 

These updates will:

• Reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
• Include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• Include assistant surgeon eligibility in accordance with the policy
• Include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
• Apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) for the same member

 

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You no longer need to pick up the phone or head to the fax machine to check the status of an authorization request or update a case. Anthem Blue Cross and Blue Shield (Anthem) has added new features to Interactive Care Reviewer (ICR), our online medical and behavioral health authorization tool to improve your digital self-service experience.

 

• Do you need to update a case that was submitted by phone or fax? Now you can add clinical notes and make other updates to these authorization requests through ICR. To make the update you need to have the Authorization & Referral Request role assigned to you by your Availity Administrator.
  • To locate the case, log on to the Availity Portal and select Patient Registration | Authorizations & Referrals, then choose Auth/Referral Inquiry.
  • Search for the case in ICR by Member, Reference/Authorization Request Number, or by Date Range.
  • From the ICR Case Overview screen select Update Case to update service codes, provider information or clinical notes. If you only need to make changes or add to your notes, select Update Clinical. Select Submit Update to complete the request.

 

• We’ve removed the guesswork from the notes that are recommended for many standard authorization requests. ICR provides a check list of the supporting clinical information that will assist Anthem with completing the review. The list is located on the Clinical Details You can upload notes, images and photos directly through ICR. You can include the documentation immediately or you can submit your request then return to the case in ICR later and select Update Clinical to add the missing information.

 

• Check the status of a submitted case at a glance. The ICR UM tracker, located on the Case Overview screen provides a quick view of where the case is in the review process. You can view when Anthem received the request, when the clinical review is underway and completed and the final decision.

 

• Additionally, we’ve added a new application to Payer Spaces, Chat with Payer, that you can use to check the status of a submitted authorization request. This is a great option if you don’t have the role assignments required to access ICR and research a case.
  • To access the Chat with Payer application from Availity’s home page, select Payer Spaces | Chat with Payer. Complete the form with the required information. You need to include the patient name, birth date and health plan member ID number. Choose Authorization Status as your topic for chat to conduct a live chat with a representative.

 

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Find Care, the doctor finder and transparency tool in Anthem Blue Cross and Blue Shield (Anthem)’s online directory, provides many Anthem members with the ability to search and compare cost and quality measures for in-network providers using the secure member portal at anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, name, or personalized match.

 

Beginning March 1, 2021, the personalized match sorting option will be available for searches by procedure type. This sorting option is based on algorithms which will use a combination of member and provider features to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions and demographics. Provider factors such as surgeon-facility pairing (an individual provider who performs a procedure at a specific facility), cost efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.

 

These member and provider features will be combined to generate a unique ranking of surgeon-facility pairings or facility providers for each member conducting the procedure search. Surgeon-facility pairings with the highest overall ranking within the search radius will be displayed first with other pairings displayed in descending order based on overall rank and proximity to the center of the search radius.

 

The personalized match methodology for specialty-based searches remains unchanged. Members continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology has no impact on member benefits.

 

• Providers may review a copy of the new sorting methodology which has been posted on Availity – our secure Web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Provider Procedure Search Methodology.pdf.

 

• If you have general questions about the Find Care tool or this new sorting option, please contact Provider Services.

 

• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors, you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.

 

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. 

 

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You’re invited!

 

In this 60-minute webinar, you will learn how to use Availity's* Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.

 

We will explore new key workflow options to fit your organization’s needs, including how to:

• Work a request in the inbox of your Attachments Dashboard.
• Enter and submit a web claim including supporting documentation.
• Use EDI batch options to trigger a request in your inbox.
• Track attachments you submitted using sent and history lists in your Attachments Dashboard.
• Get set up to use these tools.

 

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

 

Register for an upcoming webinar session:

 

1. In the Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     • To find this specific live session quickly, use keyword medattach.
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

 

Webinar Dates and Times:

 

DATE	TIME
Friday, January 8, 2021	1:00 p.m. to 2:00 p.m. Eastern time
Tuesday, January 19, 2021	3:00 p.m. to 4:00 p.m. Eastern time

 

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Reduce the amount of time spent on transactional tasks by more than 50 percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

 

The Provider Digital Engagement Supplement outlines Anthem Blue Cross and Blue Shield (Anthem) provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits – all in one comprehensive resource. Find it on anthem.com > Providers > Forms & Guides > Digital Tools.

 

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit anthem.com and use the Log In button for access to our secure provider portal, or via the Availity EDI website.

 

Accept digital member ID cards

• Save time by accepting the digital member ID card when presented by the member via their App or email.

 

Register for EFT to get funds faster

• Electronic Funds Transfer (EFT) eliminate the need for paper checks. Safe, secure and faster, payments are deposited directly to your bank account. Register here.

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

 

We appreciate your health care team going digital with Anthem as of January 1, 2021, enabling us to realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

 

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Across the nation, too many women continue to experience pregnancy-related complications and death. More than 700 women die each year in the United States as a result of complications related to pregnancy or delivery.¹ Many of these deaths are preventable. In addition, significant racial and ethnic disparities exist in maternal morbidity and mortality. For example, Black/African American and American Indian/Alaska Native women are two to three times more likely to die from pregnancy-related complications compared to White women.² Anthem Blue Cross and Blue Shield recognizes your role at the front lines of defense to support your diverse pregnant and postpartum patients. We want to ensure you have the right tools and resources to help your patients understand their risks and key maternal warning signs.

 

The Centers for Disease Control and Prevention (CDC) recently launched the Hear Her campaign to raise awareness of pregnancy-related complications, risks and death. The Hear Her campaign aims to increase knowledge of the symptoms women should seek medical attention for during pregnancy and in the year after delivery, such as vision changes and chest pain. Resources are available for pregnant and postpartum women, partners, families and friends, and health care providers.

 

The Hear Her campaign reminds us of the importance of listening to women. As a health care provider, you have an opportunity to listen to pregnant women, engage in an open conversation to make certain their concerns are adequately addressed, and help your patients understand urgent maternal warning signs. You can find more information on the CDC's Hear Her campaign at www.cdc.gov/hearher.

 

In addition, the Council on Patient Safety in Women's Health Care developed a tool to help women identify urgent maternal warning signs. The Urgent Maternal Warning Signs tool helps women recognize the symptoms they may experience during and after pregnancy that could indicate a life-threatening condition. The tool also provides additional information on the symptoms and conditions that place women at increased risk for pregnancy-related death. You can find the Council on Patient Safety in Women's Health Care Urgent Maternal Warning Signs tool at www.safehealthcareforeverywoman.org/urgentmaternalwarningsigns.

 

If you have a pregnant member in your care who would benefit from case management, please call us at 1‑866‑408-6132 for Hoosier Healthwise; 1-844-533-1995 for Healthy Indiana Plan; 1-844-284-1798 for Hoosier Care Connect. Members can also call our 24/7 NurseLine at the number on their member ID card.

 

References

1. Centers for Disease Control and Prevention. (2020, August 13). Reproductive Health: Maternal Mortality. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality/index.html.
2. Centers for Disease Control and Prevention. (2019, September 5). Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths. Retrieved from https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html.

Please continue to check Provider Communications & Updates on the provider webpage for the latest information, including:

 

• New specialty pharmacy medical step therapy requirements
  
  
• Policy Update — Nurse Practitioner and Physician Assistant Services, Professional
  
  
• Prepayment coding validation review process

Consumer Assessment of Healthcare Providers and Systems (CAHPS)^® is an annual standardized survey conducted to assess consumer experience with their health care services and health plan. Providers and their staff play a key role in the member experience. Several questions specific to the member’s experience with their provider are included in the CAHPS survey. Education about the CAHPS survey, the importance of focusing on the patient experience and ways to improve the patient experience are included in the Provider Orientation and available by visiting the anthem.com/inmedicaiddoc web page.

 

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Anthem Blue Cross and Blue Shield is now using the Notification Center on the Availity* Portal home page to communicate vital and time sensitive information. You will see a Take Action call out and a red flag in front of the message to make it easy to see new items requiring your attention.

 

We will use the Notification Center to update your organization if there are payment integrity requests for medical attachments or recommended training in the Custom Learning Center. Select the Take Action icon to access the custom learning recommended course.

 

There will also be a message posted in the Notification Center when a payment dispute decision is available. Selecting the Take Action icon will allow easy access to your appeals worklist for details.

 

Viewing the Notification Center updates should be included as part of your regular workflow so that you are aware of any outstanding action items.

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply on precertification initiation or renewal in addition to the current medical necessity review of all drugs noted below.

 

The clinical criteria below will be updated to include the requirement of a preferred agent effective

January 1, 2021.

 

Clinical criteria	Preferred drug	Nonpreferred drug
ING-CC-0107	Mvasi (Q5107), Zirabev (Q5118)	Avastin (J9035)

 

The Clinical Criteria is publicly available on www.anthem.com/inmedicaiddoc.

 

What if I need assistance?

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

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

Anthem Blue Cross and Blue Shield (Anthem) reviews the activities of the Food and Drug Administration (FDA)’s approval of drugs and biologics on a regular basis to understand the potential effects for our providers and members.

 

The FDA approves new drugs and biologics using various pathways. Recent studies on the effectiveness of drugs and biologics going through different FDA pathways illustrate the importance of clinicians’ awareness of the clinical data behind a drug or biologic approval in making informed decisions.

 

Here is a list of the approval pathways the FDA uses for drugs/biologics:

• Standard review — The standard review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public; watches for problems once drugs and biologics are available to the public; monitors drug/biologic information and advertising; and protects drug/biologic quality. Follow this link to learn more about the standard review process.

• Fast track — Fast track is a process designed to facilitate the development and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Follow this link to learn more about the fast track process.
• Priority review —A priority review designation means FDA’s goal is to take action on an application within six months. Follow this link to learn more about the priority review process.
• Breakthrough therapy — This process is designed to expedite the development and review of drugs/biologics which may demonstrate substantial improvement over available therapy. Follow this link to learn more about the breakthrough therapy review process.
• Orphan review — This refers to the review of drugs that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Follow this link to learn more about the orphan drug review process.
• Accelerated approval — These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. To learn more about the accelerated approval process, follow this link.

 

New molecular entities approvals: January 2020 through August 2020

Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.

 

Anthem reviews the FDA-approved NMEs on a regular basis. To facilitate the decision-making process, we are providing a list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized.

 

Note: This information has no impact on our standard prior authorization/pre-certification process.

 

Generic name	Trade name	Standard review	Fast track	Priority	Break-through therapy	Orphan review	Accelerated approval	Approval date	Indication
Abametapir	Xeglyze	X						7/24/2020	Head lice
Amisulpride	Barhemys	X						2/26/2020	Postoperative nausea and vomiting
Avapritinib	Ayvakit		X	X	X	X		1/9/2020	PDGFRa exon 18 mutant gastrointestinal stromal tumor
Belantamab mafodotin	Blenrep			X	X	X	X	8/05/2020	Multiple myeloma
Bempedoic acid	Nexletol	X						2/21/2020	Dyslipidemia
Brexucabtagene autoleucel	Tecartus			X	X	X	X	7/24/2020	Mantle cell lymphoma
Capmatinib	Tabrecta			X	X	X	X	5/6/2020	Non-small cell lung cancer (NSCLC)
Decitabine/ cedazuridine	Inqovi			X		X		7/07/2020	Myelodysplastic syndromes
Eptinezumab-jjmr	Vyepti	X						2/21/2020	Migraine prevention
Fostemsavir	Rukobia		X	X	X			7/02/2020	Human immunodeficiency virus (HIV) treatment
Inebilizumab	Uplizna	X			X	X		6/11/2020	Neuromyelitis optica spectrum disorder
Isatuximab	Sarclisa	X				X		3/2/2020	Multiple myeloma
Lurbinectedin	Zepzelca			X		X	X	6/15/2020	NSCLC
Nifurtimox	Lampit			X		X	X	8/06/2020	Chagas disease
Oliceridine	Olinvyk	X	X					8/07/2020	Moderate to severe acute pain
Opicapone	Ongentys	X						4/24/2020	Parkinson’s disease
Osilodrostat	Isturisa	X				X		3/6/2020	Cushing’s disease
Ozanimod	Zeposia	X						3/25/2020	Multiple sclerosis
Peanut (Arachis hypogaea) allergen powder-dnfp	Palforzia	X	X		X			1/31/2020	Peanut allergy
Pemigatinib	Pemazyre			X	X	X	X	4/17/2020	Cholangiocarcinoma
Remimazolam	Byfavo	X						7/02/2020	Sedation for procedures
Rimegepant	Nurtec ODT			X				2/27/2020	Migraine treatment
Risdiplam	Evrysdi		X	X	X	X		8/07/2020	Spinal muscular atrophy
Ripretinib	Qinlock		X	X	X	X		5/15/2020	Gastrointestinal stromal tumor
Sacituzumab-hziy	Trodelvy		X	X	X	X	X	4/22/2020	Triple negative breast cancer
Selpercatinib	Retevmo			X	X	X	X	5/8/2020	NSCLC and thyroid cancers
Selumetinib	Koselugo		X	X	X	X		4/10/2020	Neurofibromatosis type 1
Tafasitamab	Monjuvi	X	X		X	X	X	7/31/2020	Large B-cell lymphoma
Tazemetostat	Tazverik			X		X	X	1/23/2020	Epithelioid sarcoma
Teprotumumab-trbw	Tepezza		X	X	X	X		1/21/2020	Thyroid eye disease
Triheptanoin	Dojolvi	X	X			X		6/30/2020	Long-chain fatty acid oxidation disorders
Tucatinib	Tukysa		X	X	X	X		4/17/2020	Breast cancer
Viltolarsen	Viltepso		X	X		X	X	8/12/2020	Duchenne muscular dystrophy

 

Source: www.fda.gov

This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

 

In order to communicate more efficiently with providers, Anthem Blue Cross and Blue Shield (Anthem) is now sending some bulletins, policy change notifications, prior authorization update information, educational opportunities and more to providers via email. Email is the quickest and most direct way to receive important information from Anthem.

 

What do we need from you?

To receive email from Anthem (including some sent in lieu of fax or mail), submit your information via the contact form located on the provider website at anthem.com/inmedicaiddoc.

 

When multiple email addresses, NPIs or TINs exist, you need to submit all required fields separately for each individual provider or provider within a group. However, please keep in mind that we can only accept one email address for each unique provider record.

 

What if you need assistance?

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

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798
• Medicare Advantage: Call the number on the back of the member ID card

 

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Please continue to read news and updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

 

• Medicare Advantage Group Retiree Quick Reference Guide and FAQ
  
  
• Medicare Advantage Group Retiree Member Eligibility, Alpha Prefix FAQ
  
  
• SNF admission reporting requirements for D-SNP plans
  
  
• Policy Update: Nurse Practitioner and Physician Assistant Services - Professional
  
  
• Updates to AIM Clinical Appropriateness Guidelines for Radiation Oncology

 

Effective January 1, 2021, Roman Catholic Diocese of Gary will offer a Medicare Preferred (PPO) Medicare Advantage Plan with Part D (MAPD) through Anthem Blue Cross and Blue Shield (Anthem). Retirees with Medicare Parts A and B are eligible to enroll in the MAPD plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. The MAPD plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as an annual routine physical exam, hearing, LiveHealth Online* and SilverSneakers^®.*

 

The prefix on Roman Catholic Diocese of Gary member ID cards will be YVK. The cards will also show the Roman Catholic Diocese of Gary name and National Access Plus icon.

 

Providers may submit claims electronically using the electronic payer ID for the Anthem plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Claims should not be filed with original Medicare. Contracted and non-contracted providers may call the Provider Services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about Roman Catholic Diocese of Gary member benefits or coverage.

 

Detailed prior authorization requirements also are available to contracted providers by accessing the Availity Portal* at availity.com.

 

* LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.
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The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare risk adjustment and documentation guidance (General):

• Series: Offered the first Wednesday of each month from 1:00 to 2:00 P.M. (ET)*
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity, Medicare risk adjustment and documentation guidance, from January 8, 2020 to December 2, 2020, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

To learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at this link: https://bit.ly/2TYMgbn

* Note: Dates may be modified due to holiday scheduling

 

Medicare risk adjustment, documentation and coding guidance (Condition specific)

• Series: Offered the third Wednesday of each month from 1:00 to 2:00 P.M. (ET)
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity, Medicare risk adjustment documentation and coding guidance, from January 15, 2020 to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

 

For those interested in the following training topics, please register at this link: https://bit.ly/2IgxDO9

* Note: Enter the password provided, and the recording will play upon registration.

• Red flag HCCs
• Neoplasms
• Acute, chronic and status conditions
• Diabetes mellitus and other metabolic disorders
• Coinciding conditions in risk adjustment models

 

Please note that the original training events have been modified due to a transition within WebEx as of August 1, 2020. The date and time of the events have not changed but the program link and invitation detail have been updated. Previously registered participants will need to re-register for a training event using the updated registration link(s) provided in this announcement.

 

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The following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging for claims with dates of service on and after March 14, 2021.

 

Chest imaging, and head and neck imaging

Hoarseness, dysphonia and vocal cord weakness/paralysis — primary voice complaint:

• Required laryngoscopy for the initial evaluation of all patients with primary voice complaint

 

Brain imaging, and head and neck imaging

Hearing loss:

• Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed
• Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss
• Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance

Tinnitus:

• Removed sudden onset symmetric tinnitus as an indication for advanced imaging

 

Head and neck imaging

Sinusitis/rhinosinusitis:

• Added more flexibility for the method of conservative treatment in chronic sinusitis
• Required conservative management prior to repeat imaging for patients with prior sinus CT

Temporomandibular joint dysfunction:

• Removed requirement for radiographs/ultrasound

Cerebrospinal fluid (CSF) leak of the skull base:

• Added scenario for management of known leak with change in clinical condition

 

Brain imaging

Ataxia, congenital or hereditary:

• Combined with congenital cerebral anomalies to create one section

Acoustic neuroma:

• More frequent imaging for a watch and wait or incomplete resection
• New indication for neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2
• More frequent imaging when MRI shows findings suspicious for recurrence
• Single post-operative MRI following gross total resection
• Included pediatrics with known acoustics (rare but NF 2)

Tumor — not otherwise specified:

• Repurposed for surveillance imaging of low grade neoplasms

Seizure disorder and epilepsy:

• Limited imaging for the management of established generalized epilepsy
• Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

Headache:

• Removed response to treatment as a primary headache red flag
• Include pregnancy as a red flag risk factor

Mental status change and encephalopathy:

• Added requirement for initial clinical and lab evaluation to assess for a more specific cause

 

Oncologic imaging

General enhancements — Updates to Scope/Definitions, general language standardization

General content enhancements — Overall alignment with current National Comprehensive Cancer Network (NCCN) recommendations, resulting in:

• Removal of indications/parameters not addressed by NCCN
• Average risk inclusion criteria for CT colonography
• New allowances for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
• New indications for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
• Updated standard imaging prerequisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, esophageal/GE junction, gastric and non-small cell lung cancers
• Additional PET/CT management scenarios for cervical cancer, Hodgkin Lymphoma

 

Other content enhancements by section

 

Cancer screening: New indication for pancreatic cancer screening

 

Breast cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy

 

Prostate cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE

 

Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM Specialty Health^®* (AIM) in one of several ways:

• Access the AIM ProviderPortal_SM directly at aimspecialtyhealth.com/providerportal.
  • Online access is available 24/7 to process orders and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity* Portal at availity.com.
• Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. CT

 

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 here.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health_®* (AIM) Advanced Imaging of the Heart and Diagnostic Coronary Angiography Clinical Appropriateness Guidelines.

 

Evaluation of patients with cardiac arrhythmias:

• Updated repeat transthoracic echocardiography (TTE) criteria.
• Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia.

 

Evaluation of signs, symptoms or abnormal testing:

• Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature.

 

Diagnostic coronary angiography:

• Updated criteria to evaluate patients with suspected congenital coronary artery anomalies.

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM Specialty Health^®* (AIM) in one of several ways:

• Access the AIM ProviderPortal_SM directly at aimspecialtyhealth.com/providerportal.
  • Online access is available 24/7 to process orders and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity* Portal at availity.com.
• Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. CT

 

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 here.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

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On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 August 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, use this email.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield (Anthem). Availity, LLC is an independent company providing administrative support services on behalf of Anthem.

 

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