 Provider News IndianaJanuary 2024 Provider Newsletter Contents Education & Training | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | May 1, 2023 Ready, set, renew!Quality Management | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 7, 2023 HEDIS diabetes documentation
INBCBS-CDCRCM-047204-23 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Administrative | Commercial / Medicare Advantage / Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | January 1, 2024 New requirements for credentialing and recredentialingThe National Committee on Quality Assurance (NCQA) has advised Durable Medical Equipment (DME) providers are to be considered within the scope of an entity’s credentialing program for accreditation purposes. Starting February 2024, recredentialing of the existing Durable Medical Equipment Providers and Prosthetic and Orthotic Suppliers (DMEPOS) network will begin. You will receive communication asking you to either complete an application or to supply us with any of the following information: - Copy of all federal, state, and/or local licenses required to operate as a healthcare facility (by location)
- Copy of accreditation certificate or letters if accredited
- Copy of most recent CMS or state survey (with deficiencies) including cover letter from CMS or state agency stating facility is in substantial compliance or Corrective Action Plan if deficiencies were cited if not accredited is required
Please respond to these communications as quickly as possible so no disruption in service to our members or to you occurs. Contact information for questions related to this change will be included in the outreach sent. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. The Credentialing team looks forward to working with you. What if I need assistance?If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services for Medicaid at: - Hoosier Healthwise: 866-408-6132
- Healthy Indiana Plan: 844-533-1995
- Hoosier Care Connect: 844-284-1798
For the Provider Services phone number for Medicare Advantage and Commercial please refer providers to the number on the back of their patient’s member ID card. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. INBCBS-CDCRCM-041405-23-CPN39398 According to ICD-10-CM guidelines for coding and reporting, it is inappropriate to bill certain diagnosis codes as a primary or first listed diagnosis. Instead, these codes should always be sequenced as a secondary or subsequent diagnosis. Effective for claims processed on or after April 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny: - Professional claims submitted on a CMS-1500 form that report inappropriate primary diagnosis codes as the only diagnosis on the claim or claim line; and facility claims submitted on a CMS-1450 form that report inappropriate primary diagnosis codes as the principal diagnosis or only code on the claim.
As provided by ICD-10-CM guidelines, inappropriate primary diagnosis codes include but are not limited to: - External Cause Codes of Morbidity (V, W, X, or Y codes [ICD-10-CM]) describes an environmental event causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. These codes are intended to be supplemental to the principal or primary diagnosis code indicating the nature of the condition. In addition, based on this guideline, a diagnosis code of external causes cannot be the only diagnosis on the claim.
- Manifestation Codes: Certain conditions contain both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD Manual coding guidelines have established a coding convention that requires the underlying condition to be sequenced first followed by the manifestation. According to the ICD Manual coding guidelines, the primary, first listed, or principal diagnosis cannot be a manifestation code. In addition, based on this guideline, a manifestation code cannot be the only diagnosis on the claim.
- Sequela Codes: a sequela (7th character "S") code cannot be listed as the primary, first listed, or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code. In addition, based on this guideline, a sequela (7th character "S") code cannot be the only diagnosis on a claim.
- Secondary Diagnosis: According to ICD guidelines, a secondary diagnosis code can only be used as a secondary diagnosis. Since these codes are only for use as supplemental codes, any procedure or service received with a secondary diagnosis code as the principal or primary diagnosis will be denied as incorrectly coded.
EOB Message: We denied this service since it was reported incorrectly. Per CMS (Federal) correct coding guidelines, specific Supplementary Classification ICD-10 codes cannot be used as the primary diagnosis or as the only diagnosis on the claim. Ex-Codes: 00V16 and v16 Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-035113-23-CPN34788 When using or billing air ambulance services, please remember: - To facilitate timely and accurate claim processing of air ambulance services, include the facility’s record (emergency department record, or if an inpatient, the discharge or transfer summary) along with your run sheet. Providing this information will greatly facilitate timely review of medical necessity.
- Regarding the practice of using air ambulance services solely because use of ground transport would temporarily deplete local area Emergency Medical Services (EMS) availability, while EMS availability is always a local EMS concern, please understand that this reason alone does not meet medical necessity criteria for our members.
- Lastly, excess miles flown to keep a patient within the sending facility’s health system, when another closer capable receiving hospital has capacity, does not meet medical necessity criteria. Determination of medical necessity, including mode of transportation, is determined in accordance with Anthem’s clinical guidelines and medical necessity criteria. These determining guidelines include only approving the distance to the closest capable facility with capacity.
Taking the above into consideration will result in faster processing and lower denials of your air ambulance service claims. For your reference, see CG-ANC-04 Ambulance Services: Air and Water. If you have questions, contact your local provider relationship management representative. We look forward to working together to achieve improved outcomes. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047454-23-CPN47431 Effective January 1, 2024, Northrop Grumman Corporation will contract with Quantum Health to perform health care navigation and care coordination services for their active member population only. As part of this contract, Quantum Health will support member healthcare and benefit needs, including member and care provider services and medical utilization review and submission to Anthem. Northrup Grumman Corporation active members may be identified by the group number beginning with 174022 on the member ID card. A sample ID card is below. Anthem will remain responsible for claims adjudication and certain services as described below. Anthem will also remain the administrator of Behavioral Health Utilization Management, inclusive of retrospective reviews, and Case Management. Quantum Health is the point of contact for member and care provider inquiries. Quantum Health will be the point of contact for members and healthcare providers to verify: - Benefit coverage information.
- Eligibility inquiries.
- Prior-authorization submission and review (as stated above).
Anthem will remain the point of contact for care providers for the following:- Behavioral Health Utilization Management, inclusive of retrospective reviews and Case Management.
- Quantum Health will redirect care provider questions/inquiries to Anthem or local Blue for Medical and Behavioral Health Services for the following:
- Care provider contracting.
- Remittances.
- Fee schedule.
- Value Based Programs.
- Network status.
- Demographic information updates.
Sample Member ID cardBased on the information outlined above, there are changes in the Member Services and Provider Services/pre-certification phone numbers. These two new phone numbers are located on the back of the Medical Member ID card. 
If you have any questions, please contact your provider relationship management representative. We are committed to a future of shared success. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047992-23 Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed. Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. Online update options include: - Adding/changing an address location.
- Changing a name.
- Changing a phone/fax number.
- Provider leaving a group or a single location.
- Closing a practice location.
The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information helps us ensure your online provider directory information is current. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047108-23 Now accepting Medicaid and Medicare member claimsAs a care provider taking advantage of digital requests for additional information (Digital RFAI), you know it is the most efficient way to send the required documentation to process your Commercial member claims. As of mid-November, you also can receive Digital RFAI notifications for your Medicaid and Medicare member claims. The process will not change for Medicaid and Medicare member claims. You will still follow the same fast and easy process for our Medicaid and Medicare member claims as you do for your commercial member claims. The only change is that your Medicaid and Medicare member claims will not pend. Medicaid and Medicare member claims will deny when additional documentation is needed to process the claim. Notifications will remain on your dashboard for up to 30 days as they do today. Submit the documentation at your convenience (most care providers submit documents within seven to 14 days). Your notifications will continue to arrive on your dashboard each morning, making it convenient to plan your work; no need to check your dashboard throughout the day. Learn more!In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration: Date | Time | | January 23, 2024 | 2:30 to 3:45 p.m. ET |
Availity administrators can use this link to register for live training or to view the training on demand. For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient: Date | Time | | January 23, 2024 | 2:30 to 3:30 p.m. ET |
Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training, or to view the live training on-demand. Contact Availity Customer Support at availity.com/Contact-Us or your provider relationship representative if you have any questions. Not a Digital RFAI care provider?If you’re not already using the Digital RFAI process and want to take advantage of faster claims processing, participation is easy. 1. | Registration | The organization’s Availity administrator will register for Medical Attachments, which enables care provider organizations to receive notices from the payer and submit requested documents digitally. | All billing NPIs/TINs must be registered. | 2. | User roles | The Availity administrator will be required to update or add new users with these specific role assignments through Availity: - Claims Status
- Medical Attachments
| Enable users to view the Availity Attachment Dashboard. | 3. | Ready to go! | After the registration and user roles are completed on Availity, the Digital RFAI process is ready. | Requests will automatically appear on the Attachments Dashboard each morning (when documents are needed). |
We are committed to finding solutions that help our care provider partners offer quality services to our members. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047947-23-CPN47121 Digital Solutions | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | January 1, 2024 Filing digital claims disputes: Transparent and trackableWhen you have more information to share about a claim that has been denied, filing the dispute digitally is a cost-effective and time-saving alternative to paper and fax. You can feel confident that we have received your claims dispute when you submit it through the digital workflow. This Claim Status application feature, available on Availity.com, enables a fast, efficient, and streamlined process for filing claim disputes: - Upload supporting documentation and attach it directly to the claim.
- Use the Appeals Dashboard:
- To review digitally filed disputes.
- To retrieve correspondence related to your disputes.
- For a history of digitally filed disputes.
How to file a digital claim payment dispute:- Log on to Availity.com.
- Select the Claims & Payments tab.
- Select Claim Status and enter the information needed to retrieve your claim.
- When you have found your claim, select the Dispute button to initiate a dispute (it will be visible when your claim is eligible for a dispute).
- Access your Appeals Dashboard to upload the supporting documents, locate initiated dispute, and complete the dispute request:
- From the Claims & Payments tab, select Appeals to access your Appeals Dashboard.
In the past, you may have used the Attachment button and selected the Dispute option to dispute a claim. We’ve eliminated that process to make disputing a claim more trackable and transparent. Receive dispute determinations digitally from your Appeals DashboardWe will review the dispute and communicate an outcome on Availity.com. Check the status of a digitally submitted dispute at any time from your Appeals Dashboard. Learn moreSubmitting a digital claim payment dispute is easy, but attending informative learning sessions provides a deep dive into the application and its search and filter functions. These tips are sure to make the submission process even easier. Use this link to access on-demand training. For more information about the claim payment dispute process, consult the provider manual or reach out to your provider relationship management representative. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. INBCBS-CD-041329-23-CPN41106 Effective January 1, 2024, most specialty prescriptions will transfer to BioPlus, CarelonRx specialty pharmacy that services Anthem members. This migration is taking place in multiple waves throughout the next year. What happens next?- If you have patients affected by this pharmacy change, BioPlus will contact you to request new prescriptions, refills, or prior authorizations. You will also receive a letter from CarelonRx.
- Current specialty prescriptions with open refills will automatically transfer to BioPlus.
- Impacted patients will receive a letter and a phone call, explaining this transition.
- There is nothing you or your patients need to do except speak with BioPlus when they call.
What is the benefit to you and your patients?CarelonRx and BioPlus work together to deliver patients an unparalleled level of high-tech, high-touch service that focuses on their whole health. As a care provider, you will receive fast and easy benefit confirmation and prior authorizations for expedited time to therapy. BioPlus also offers comprehensive infusion services that include dedicated nurse concierges, patient advocates, and disease-specific education and clinical reminders. If you have any questions, please call your Anthem representative. We’re here to help. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047443-23-CPN47164 Education & Training | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | May 1, 2023 Ready, set, renew!It’s time for some of your patients to renew their Medicaid benefits. As states begin to recommence Medicaid renewals, we want to ensure you have the information needed to help your Medicaid patients renew their healthcare coverage. Some patients have never had to renew their coverage at all, while other patients may have forgotten the process entirely. We’re here to help. What steps do my patients need to take? - Ready: Patient gets their documents ready.
- Set: Patient ensures their form is all set
- Renew: Patient sends renewal form via:
What if I need assistance? Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat. For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. INBCBS-CD-017953-22-CPN16407, INBCBS-CD-047500-23-CPN047298, INBCBS-CD-056720-24-CPN56608 Policy Updates | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 15, 2023 Omidubicel prior authorization updateEffective February 1, 2024, Omidubicel will require prior authorization (PA). Medical Policy MED.00147 will be applied for PAs related to Omidubicel. All covered services are contingent upon medical necessity and benefit coverage at the time of service. The precertification lookup tool allows providers to search codes by the specific line of business (such as Hoosier Healthwise, Healthy Indiana Plan [HIP], or Hoosier Care Connect) to determine if PA is required and which guideline is utilized for the case review. To access the precertification lookup tool, go to the provider website and select Precertification lookup tool under the Claims drop-down. Detailed PA requirements are available to contracted providers via the provider self-service tool on Availity Essentials or go to the provider website and select Log in to Availity. For assistance with questions regarding the PA requirement change, please call Provider Services at one of the phone numbers listed below: - Hoosier Healthwise: 866-408-6132
- HIP: 844-533-1995
- Hoosier Care Connect: 844-284-1798
Clinical Utilization Management Guidelines (CUMG) number | CUMG title | CPT® code | Med.00147 | Cellular Therapy Products for Allogeneic Stem Cell Transplantation | Specific drug code TBD. For all unclassified codes (for example, J3490), a PA is required. |
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. INBCBS-CD-040844-23 On August 18, 2023, and August 30, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other providers in your practice and office staff. Note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | January 8, 2024 | *CC-0244 | Columvi (glofitamab-gxbm) | New | January 8, 2024 | *CC-0245 | Izervay (avacincaptad pegol) | New | January 8, 2024 | *CC-0246 | Rystiggo (rozanolixizumab-noli) | New | January 8, 2024 | *CC-0247 | Beyfortus (nirsevimab) | New | January 8, 2024 | CC-0001 | Erythropoiesis Stimulating Agents | Revised | January 8, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised | January 8, 2024 | CC-0104 | Levoleucovorin Agents | Revised | January 8, 2024 | CC-0100 | Romidepsin | Revised | January 8, 2024 | *CC-0182 | Iron Agents | Revised | January 8, 2024 | CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised | January 8, 2024 | CC-0176 | Beleodaq (belinostat) | Revised | January 8, 2024 | CC-0180 | Monjuvi (tafasitamab-cxix) | Revised | January 8, 2024 | CC-0107 | Bevacizumab for non-ophthalmologic indications | Revised | January 8, 2024 | CC-0216 | Opdualag (nivolumab and relatlimab-rmbw) | Revised | January 8, 2024 | CC-0196 | Zynlonta (loncastuximab tesirine-lpyl) | Revised | January 8, 2024 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised | January 8, 2024 | CC-0203 | Ryplazim (plasminogen, human-tvmh) | Revised | January 8, 2024 | CC-0193 | Evkeeza (evinacumab) | Revised | January 8, 2024 | *CC-0034 | Hereditary Angioedema Agents | Revised | January 8, 2024 | *CC-0041 | Complement Inhibitors | Revised | January 8, 2024 | *CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised | January 8, 2024 | CC-0028 | Benlysta (belimumab) | Revised | January 8, 2024 | *CC-0243 | Vyjuvek (beremagene geperpavec) | Revised | January 8, 2024 | CC-0165 | Trodelvy (sacituzumab govitecan) | Revised | January 8, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised | January 8, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised | January 8, 2024 | CC-0143 | Polivy (polatuzumab vedotin-piiq) | Revised | January 8, 2024 | *CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-044412-23-CPN44137 Effective for dates of service on and after April 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc. CPT® code | Description | 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and phenotype | 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure) | 0131U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure) | 0132U | Hereditary ovarian cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure) | 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) | 0135U | Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure) | 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite insta | 0287U | Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict | 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an | 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider | 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) | 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations | 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 a | 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement | 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, | 0388U | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct | 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti | 0397U | Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, del | 0400U | Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie | 0401U | Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a |
As a reminder, ordering and servicing care providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access the Carelon Medical Benefits Management ProviderPortalSM directly at providerportal.com:
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access Carelon Medical Benefits Management via Availity Essentials at Availity.com
For questions related to guidelines, please contact via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-041252-23-CPN40788 Medical Policy & Clinical Guidelines | Commercial / Medicare Advantage | December 28, 2023 Change to Prior Authorization Requirements Transition to Carelon Medical Benefits Management, Inc. cardiology guidelinesEffective April 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management, Inc. guidelines to perform medical necessity/clinical appropriateness reviews for requested cardiology interventions. Applicable CPT® codes lists are included in each guideline linked below: Preapproval requirements remain the same. The requested services received on or after April 1, 2024, will be reviewed with the new Clinical Criteria. As a reminder, ordering and servicing care providers may submit preapproval requests to Carelon Medical Benefits Management using the 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. For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. We are focused on reducing administrative burdens, so you can do what you do best – care for our members. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-042161-23-CPN41724 Medical Policy & Clinical Guidelines | Commercial / Medicare Advantage | January 1, 2024 Change to Prior Authorization Requirements Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services. Refer
to attachment to view full details. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. MULTI-BCBS-CRCM-043720-23-CPN42002 ATTACHMENTS (available on web): Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines (pdf - 0.11mb) Medical Policy & Clinical Guidelines | Commercial | January 1, 2024 Change to Prior Authorization Requirements Carelon Medical Benefits Management, Inc. genetic testing CPT® code list updateEffective for dates of service on and after April 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc. CPT code | Description | 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and phenotype | 0130U | Hereditary colon cancer disorders (such as Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in | 0131U | Hereditary breast cancer-related disorders (such as hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure) | 0132U | Hereditary ovarian cancer-related disorders (such as, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure) | 0134U | Hereditary pan cancer (such as, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) | 0135U | Hereditary gynecological cancer (such as, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure) | 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite insta | 0287U | Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict | 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an | 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider | 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) | 0242U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements | 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 | 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement | 0388U | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct | 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti | 0397U | Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, del | 0400U | Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie | 0401U | Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score |
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of the following ways: - Access Carelon’s ProviderPortalSM directly at providerportal.com:
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access Carelon Medical Benefits Management via the Availity platform at Availity.com.
For questions related to guidelines, please contact Carelon Medical benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-041131-23-CPN40786 Prior Authorization | Commercial | January 1, 2024 Change to Prior Authorization Requirements Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024As communicated in the October 2023 provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable. The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management expanded cardiology, genetic testing, radiology, musculoskeletal, surgical and radiation oncology programs. The Clinical Guidelines and Medical Policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1, 2024, and after. Members included in the new programAll fully insured, self-funded (ASO), HealthLink, and National members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of April 1, 2024. A separate notice will be published for Medicare Advantage, Medicare, and MA GRS. Members of the following products are excluded: Medicaid, Medicare supplement, Federal Employee Program® (FEP®). Pre-service review requirementsTo determine if prior authorization is needed for a member on or after April 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials website to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management). For procedures that are scheduled to begin on or after April 1, 2024, all providers with the following programs must contact Carelon Medical Benefits Management to obtain pre-service review for the services including but not limited to the following non-emergency modalities. Please refer to the Clinical Guidelines on the microsite resource pages for complete code lists. Note: The procedure list has been updated since the November notification. All codes will only be reviewed for medical necessity for the requested service and not for site of care at this time. Program | Services | Clinical Guidelines | Expanded cardiology | - Treatment of varicose veins
- Artery stent placement w/wo angioplasty
- Embolization procedure
- Dialysis circuit procedure
- EPS studies
- Cardiac ablation
- Cardiac monitor device
- Cardiac contractility modulation
- Wearable cardioverter defibrillators
- Wireless CRT for left ventricular pacing
- Venous angioplasty w/wo stent placement
- Vein embolization treatment for pelvic congestion syndrome and varicocele
- PFO closure devices
| - CG-MED-64
- CG-MED-74
- CG-SURG-28
- CG-SURG-55
- CG-SURG-76
- CG-SURG-83
- CG-SURG-93
- CG-SURG-106
- MED.00055
- RAD.00059
- SURG.00032
- SURG.00037
- SURG.00062
- SURG.00152
- SURG.00153
- THER-RAD.00012
| Genetic testing | - Topographic genotyping
- Chromosomal microarray analysis
- Gene expression profiling
- Gene mutation testing
- Gene sequencing
- Panel and other multi-gene test for polymorphisms
- Genetic test for inherited diseases
- Molecular marker evaluation of thyroid nodules
- Hybrid personalized molecular residual disease test for cancer
- BRCA gene test
- Cell-free DNA test to aid in monitoring of kidney transplant rejection
- Laboratory test to aid in dx of heart transplant rejection
| - Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
- Cell-free DNA Testing (Liquid Biopsy) for the Management of Cancer
- Chromosomal Microarray Analysis
- Genetic Testing for Inherited Conditions
- Hereditary Cancer Testing
- LAB.00025
- LAB.00050
- Pharmacogenomic Testing
- Polygenic Risk Scores
- Somatic Tumor Testing
- Whole Exome Sequencing and Whole Genome Sequencing
| Radiology | - Radiostereometric analysis
- Quantitative ultrasound for tissue characterization
- Myocardial sympathetic innervation and imaging w/wo spect.
- Lumbar discography
| - CG-SURG-29
- RAD.00064
- RAD.00065
- RAD.00067
| Musculoskeletal | - Extraosseous subtalar joint imp and arthroereisis
- Genicular Nerve block and ablation — CHR knee pain
- Percutaneous and endo spinal surgery
- Implanted devices for spinal stenosis
- Percutaneous vert disc and endplate procedures
- Cryoablation for podiatric conditions
| - SURG.00052
- SURG.00071
- SURG.00092
- SURG.00100
- SURG.00104
- SURG.00142
| Surgical | - Wireless capsule endoscopy
- Bariatric surgery
- Paraoesophageal hernia repair
- Ablation proc. — treatment of Barrett’s esophagus
- Transendoscopic therapy for GE reflux/dysphagia/gastroparesis
- Lower esophageal sphincter augmentation devices
| - CG-SURG-83
- CG-SURG-92
- CG-SURG-101
- MED.00090
- SURG.00047
- SURG.00131
| Radiation oncology | - Hyperthermia for cancer therapy
| |
Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com to register. For more informationFor resources to help your practice get started with the radiology, expanded cardiology, genetic testing, musculoskeletal, surgical, and radiation oncology programs, go to: These websites include helpful information and tools such as order entry checklists, Clinical Guidelines, and FAQs. You can also call your local provider relationship management representative if you have any questions. We value your participation in our network and look forward to working with you to help improve the health of our members. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047241-23 As communicated in the November 2023, provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross and Blue Shield members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable. The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical, and Radiation Therapy programs. Refer
to attachment to view full details Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-045225-23-CPN44885 ATTACHMENTS (available on web): Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024 (pdf - 0.73mb) Welcome to our monthly provider newsletter: stay informed We are thrilled to include our dental providers in our monthly provider newsletter. In these monthly publications, we will communicate important updates, informative educational articles, and more. New articles are published on the first business day of each month, so be sure to bookmark this location and visit this page regularly for updates. Our dedicated team is committed to making important information easy for you to find, so that you can continue providing excellent care to your patients. Consolidated Appropriations Act provider directory federal mandate – provider directories effective January 1, 2022 As required by the Consolidated Appropriations Act (CAA) and several state laws, we must ensure our provider directories are accurate. Your patients, our members, need the most up-to-date information to reach you. Please keep us informed of any changes impacting you or your office, especially those changes impacting the directory. We will reach out to our contracted providers as required by Federal and State laws to verify contact information. As a contracted provider, you must respond to the notification by providing updated contact information. We appreciate your due diligence in keeping us informed of any changes impacting you or your office. Working together, we ensure your patients, our members, can reach you quickly while we meet our compliance obligations. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-DEN-047183-23-CPN47030 Pharmacy | Commercial | December 28, 2023 Change to Prior Authorization Requirements Specialty pharmacy updates — January 2024Specialty pharmacy updates for 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 Carelon Medical Benefits Management, Inc., a separate company. Note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications. Inclusion of the National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. Prior authorization updatesCorrection: In the August 2023 edition of Provider News, we announced prior authorizations for Zynyz would be effective November 2023. In the September 2023 edition of Provider News, we announced prior authorizations for Epkinly would be effective December 2023. Please be advised that the prior authorization effective date for Epkinly and Zynyz is January 1, 2024. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0242* | Epkinly (epcoritamab-bysp) | C9155, J3490, J3590, J9999 | CC-0240* | Zynyz (retifanlimab-dlwr) | J9345 |
* Oncology use is managed by Carelon Medical Benefits Management. Effective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Access our Clinical Criteria to view the complete information for these prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0068 | Ngenla (somatrogon-ghla) | J3590, C9399 | CC-0018 | Pombiliti (cipaglucosidase alfa-atga) | J3490, J3590 | CC-0020 | Tyruko (natalizumab-sztn) | J3490, J3590 | CC-0248* | Elrexfio (elranatamab-bcmm) | C9165, J3590, J9999, C9399 | CC-0249* | Talvey (talquetamab-tgvs) | C9163, J3590, J9999, C9399 | CC-0250 | Veopoz (pozelimab-bbfg) | C9399, J3590 | CC-0251 | Ycanth (cantharidin) | C9164, J3490 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updatesEffective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process. The preferred product in the Tyruko step therapy is generic dimethyl fumarate. Access our Clinical Criteria to view the complete information for these step therapy updates. Clinical Criteria | Status | Drug | HCPCS or CPT code(s) | CC-0020 | Non-preferred | Tyruko (natalizumab-sztn) | J3490, J3590 |
Courtesy noticeEffective on or after October 30, 2023, step therapy criteria for vascular endothelial growth factor (VEGF) inhibitors found in Clinical Criteria document CC-0072 expands the preferred product list to include Eylea HD. Please refer to Clinical Criteria document for details. Quantity limit updatesEffective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process. Access our Clinical Criteria to view the complete information for these quantity limit updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0018 | Pombiliti (cipaglucosidase alfa-atga) | J3490, J3590 | CC-0020 | Tyruko (natalizumab-sztn) | J3490, J3590 | CC-0250 | Veopoz (pozelimab-bbfg) | C9399, J3590 | CC-0251 | Ycanth (cantharidin) | C9164, J3490 |
Site of care updatesEffective for dates of service on and after April 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process. Access our Clinical Criteria to view the complete information for these site of care updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0189 | Amondys 45 (casimersen) | J1426 | CC-0241 | Elfabrio (pegunigalsidase alfa-iwxj) | J2508 | CC-0193 | Evkeeza (evinacumab) | J1305 | CC-0044 | Exondys 51 (eteplirsen) | J1428 | CC-0154 | Givlaari (givosiran) | J0223 | CC-0231 | Lamzede (velmanase alfa-tycv) | J0217 | CC-0209 | Leqvio (inclisiran) | J1306 | CC-0013 | Mepsevii (vestronidase alfa) | J3397 | CC-0185 | Oxlumo (lumasiran) | J0224 | CC-0073 | Prolastin (alpha 1 proteinase inhibitor) | J0256 | CC-0049 | Radicava (edaravone) | J1301 | CC-0246 | Rystiggo (rozanolixizumab-noli) | J9333 | CC-0225 | Tzield (teplizumab-mzwv) | J9381 | CC-0170 | Uplizna (inebilizumab-cdon) | J1823 | CC-0172 | Viltepso (viltolarsen) | J1427 | CC-0160 | Vyepti (eptinezumab-jjmr) | J3032 | CC-0152 | Vyondys 53 (golodirsen) | J1429 | CC-0207 | Vyvgart Hytrulo (efgartigimod alfa 2 mg and hyaluronidase-qvfc) | J9334 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-047322-23 We’re committed to ensuring every eligible member receives an Annual Planned Visit (APV) this year and appreciate your help to make this happen. Tips to help your practice boost APV rates early in the year:- Members do not need to wait a full calendar year between wellness visits. Coverage resets on January 1 and we encourage all eligible members to schedule wellness visits with their care provider.
- Outreach to members within their first year of Medicare to schedule their Welcome to Medicare Exam (or Initial preventive physical exam, IPPE) and explain its importance.
- Know who your hard-to-engage members are and start contacting them earlier in the year.
- The Provider News Quality Management page is a great resource to learn more about optimizing your quality scores and staying up to date on our latest communications.
- While everyone is eligible for an annual wellness visit, some of the topics discussed during the visit may require additional follow-up to close a care gap. Be aware of scheduling lead times with other facilities for certain visit types, like mammograms, DEXA scans, and colonoscopies. Try to prioritize these patients who need these services for wellness visits.
- The AWV is a hands-off appointment that can be conducted via telehealth. This may be a great option for patients with mobility or access issues or compromised immune systems. See our guide for how to facilitate these exams via telehealth here.
APV coding guidelines:*Verify member’s benefits and eligibility prior to scheduling
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-040774-23-CPN40559 Quality Management | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | January 1, 2024 Healthy blood pressure recheck initiativeAnthem Blue Cross and Blue Shield is committed to ensuring all our members have controlled blood pressure. We’re encouraging you to recheck any elevated readings taken at the start of the appointment again before the patient leaves, in hopes of obtaining a reading of less than 140/90 mmHg. If the second reading continues to be elevated, have the member return in a few weeks for a blood pressure recheck. We’ve created a guide to help incorporate this practice into your office’s daily workflow with minimal disruption to your day. You can find the Healthy Blood Pressure Recheck Guide when you go to https://providernews.anthem.com/indiana and type “healthy blood pressure” in the search window on the left hand side of the page. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. INBCBS-CD-023978-23-CPN23630 CORRECTION: The BPD article was originally published stating the Compliance is greater than 139/89. The statement has been corrected to Compliance is less than 140/90. HEDIS® 2023 documentation for Blood Pressure Control for Patients With Diabetes (BPD)Measure descriptionThe percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg) during the measurement year. What we are looking for in provider records: - Last BP documented in 2023 regardless of reading
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Take a second BP at the end of the office visit if initial BP was > 140/90 and document new BP.
- Consider taking BP at every visit.
- Remind medical staff not to round results. Results must be precise (such as, 139/89).
- Compliance is less than 140/90.
- Counsel on healthy habits for managing high blood pressure.
- Encourage antihypertensive and other medication adherence.
- Member reported BPs during a telehealth visit are acceptable and should be documented in the members health record
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS 2023 documentation for Hemoglobin A1c Control for Patients With Diabetes (HBD) Measure descriptionThe percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) was at the following levels during the measurement year: - HbA1c control (< 8.0%)
- HbA1c poor control (> 9.0%)
What we are looking for in provider records: - Last HbA1c documented in 2023 regardless of result
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Counsel on healthy habits for managing diabetes.
- If appropriate, set an HbA1c goal of less than 7%.
- Encourage timely HbA1c testing.
- Encourage medication adherence.
- Encourage continuous glucose monitoring.
- In progress notes when documenting HbA1c value include date the test was performed.
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS 2023 documentation for Eye Exam for Patients With Diabetes (EED)Measure description The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) who had a retinal eye exam. What we are looking for in provider records: - Evidence of a retinal eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or year prior with results
- Bilateral eye enucleation any time during the member’s history
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Refer patients to an optometrist or ophthalmologist for a dilated or retinal eye exam annually.
- Fundus/retinal photography is considered imaging and is eligible for use, must be dated and interpreted by an eye care professional.
- Counsel on healthy habits for managing diabetes.
- In progress notes when documenting a retinal eye exam include the name of eye care provider or optometrist/ophthalmologist credentials, date performed, and result.
- Encourage medication adherence.
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-041667-23-CPN41092 Quality Management | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 7, 2023 HEDIS diabetes documentationCORRECTION: The BPD article was originally published stating the Compliance is greater than 139/89. The statement has been corrected to Compliance is less than 140/90. HEDIS® 2023 documentation for Blood Pressure Control for Patients With Diabetes (BPD) Measure descriptionThe percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg) during the measurement year What we are looking for in provider records:- Last BP documented in 2023 regardless of reading
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Take a second BP at the end of the office visit if initial BP was > 140/90 and document new BP.
- Consider taking BP at every visit.
- Remind medical staff not to round results. Results must be precise (such as, 139/89).
- Compliance is less than 140/90.
- Counsel on healthy habits for managing high blood pressure.
- Encourage antihypertensive and other medication adherence.
- Member reported BPs during a telehealth visit are acceptable and should be documented in the members health record
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS 2023 documentation for Hemoglobin A1c Control for Patients With Diabetes (HBD) Measure descriptionThe percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) was at the following levels during the measurement year: - HbA1c control (< 8.0%)
- HbA1c poor control (> 9.0%)
What we are looking for in provider records:- Last HbA1c documented in 2023 regardless of result
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Counsel on healthy habits for managing diabetes.
- If appropriate, set an HbA1c goal of less than 7%.
- Encourage timely HbA1c testing.
- Encourage medication adherence.
- Encourage continuous glucose monitoring.
- In progress notes when documenting HbA1c value include date the test was performed.
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS 2023 documentation for Eye Exam for Patients With Diabetes (EED) Measure descriptionThe percentage of members 18 to 75 years of age with diabetes (types 1 and 2) who had a retinal eye exam What we are looking for in provider records:- Evidence of a retinal eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or year prior with results
- Bilateral eye enucleation any time during the member’s history
- Evidence of hospice or palliative services in 2023
- Evidence patient expired in 2023
- Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes
Helpful hints:- Refer patients to an optometrist or ophthalmologist for a dilated or retinal eye exam annually.
- Fundus/retinal photography is considered imaging and is eligible for use, must be dated and interpreted by an eye care professional.
- Counsel on healthy habits for managing diabetes.
- In progress notes when documenting a retinal eye exam include the name of eye care provider or optometrist/ophthalmologist credentials, date performed, and result.
- Encourage medication adherence.
- Review diabetic services needed at each office visit.
- For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. INBCBS-CD-041656-23-CPN41092 Quality Management | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | December 4, 2023 HEDIS medical record submission made easier with our Remote EMR Access ServiceInstead of submitting medical records for the HEDIS® hybrid project, use the Remote Electronic Medical Record (EMR) Access Service provided by Anthem Blue Cross and Blue Shield (Anthem). We offer providers the ability to grant access to your EMR system directly to pull the required documentation to aid your office in reaching compliance. Granting our team remote access to your EMR helps reduce the time and costs associated with medical record retrieval while improving efficiency and allowing your office to focus on patient care. We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines: - We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We only access the least amount of information needed for a use, disclosure, or a request.
- We only save to file and do not physically print any PHI.
Getting started with Remote EMR Access is just one email away. Email Centralized_EMR_Team@anthem.com today. To learn more about our Remote EMR Access, view the frequently asked questions below. Q. How do you retrieve our medical records?A. We access your EMR using a secure website and retrieve only the necessary documentation by printing it to an electronic file we store internally, on our secure network drives. Q. Is this process secure?A. Yes, we only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives. Q. Why does Anthem need full access to the entire medical record?A. There are several reasons we need to look at the entire medical record of a member, including: - HEDIS measures can include up to a 10-year look back of a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a non-standard format, such as an in-office lab slip scanned into miscellaneous documents.
Q. What information do I need to submit to use your Remote EMR Access Service?A. Email Centralized_EMR_Team@anthem.com with the following information: Practice/facility demographic information (for example, address, National Provider ID, Taxpayer Identification Numbers, etc.) - EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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. INBCBS-CD-037985-23-CPN37863 With the New Year, people often make resolutions or set goals for themselves. Let this be the year that you see all your patients for their annual preventive care visit. As you know, annual visits are mutually beneficial to both you and your patients. These visits help establish a strong provider-patient relationship, which is essential in achieving the best healthcare outcomes. Establishing baseline measurements, knowing family history, and understanding unique risk factors and concerns can help you provide appropriate and culturally sensitive guidance on reducing risk for disease. Patients who report positive interactions with their healthcare providers demonstrate greater self-management and quality of life, as well as a reduction in emergency room visits and inpatient admissions. Start the new year on the right foot: - If you are seeing a patient for the first time, ask them to have their previous provider send their medical records.
- Begin reaching out to harder to engage patients early in the year.
- Reach out to patients at least [two months] prior to their birthday to schedule an appointment.
- Remind patients of their upcoming appointment via phone, text, and/or email as it approaches to avoid no shows.
- Remember to verify your patient’s benefits and eligibility prior to scheduling appointments.
- Screen for social needs that may be a barrier for care.
- If you need to refer a patient for a test or to a specialist, manage their expectations and follow-up with both the patient and provider.
Make sure to get the credit you deserve by reporting all services provided and use all appropriate billing codes: - The annual visit service is coded based on the patient’s age.
- Use CPT® Category II codes with your claims encounters to maximize HEDIS® data collection and reduce the burden of HEDIS medical record review. Go to the American Medical Association website at ama-assn.org for a complete list of CPT codes.
- If you are using an electronic medical record system, consider electronic data sharing with the health plan to capture all coded elements to facilitate HEDIS data collection and more accurate gap in care reports.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-045214-23-CPN44820 |