July 2021 Anthem Provider News - Indiana

Contents

Medical Policy & Clinical GuidelinesCommercialJuly 1, 2021

Reminder: Updated AIM rehabilitative program effective August 1, 2021 - Site of service reviews

Medical Policy & Clinical GuidelinesCommercialJuly 1, 2021

Medical Policy and Clinical Guideline Updates - July 2021*

Reimbursement PoliciesCommercialJuly 1, 2021

Reimbursement policy update: Consultations - Professional*

Reimbursement PoliciesCommercialJuly 1, 2021

New reimbursement policy: Non-patient laboratory services - Facility*

State & FederalMedicare AdvantageJuly 1, 2021

Medical drug benefit clinical criteria updates

State & FederalMedicare AdvantageJuly 1, 2021

Let’s Vaccinate

State & FederalMedicare AdvantageJuly 1, 2021

Medicare News - July 2021

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Member Rights and Responsibilities Statement

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Important information about utilization management

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Complex Case Management program

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

New reimbursement policy: Modifier 90: Reference (outside) laboratory and pass-through billing

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Provider education program survey: Your Voice Counts

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Continuing medical education/continuing education unit opportunities

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Medicaid News - July 2021

AdministrativeCommercialJuly 1, 2021

Register now to learn strategies to help you and your practice improve clinical quality



Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving Star ratings.

 

Program objectives:

  • Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas including telehealth, pharmacy measures, chronic disease monitoring, cancer screenings, documentation and more.
  • Apply the knowledge you gain from the webinars to improve your organization’s quality.

 

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

 

REGISTER HERE for our upcoming clinical quality webinars!

 

1230-0721-PN-CNT

AdministrativeCommercialJuly 1, 2021

Another mark of the pandemic: An increase in childhood obesity

More potato chips, sugary drinks and less physical activity are key contributors

 

In a recent study published by Pediatrics1, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed range from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

 

The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.

 

The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.

 

 

The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.

  • When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
  • When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
  • Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

 

HEDIS® measure WCC looks at the percentage of members, 3 to 17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

  • Body mass index (BMI) percentile (percentage, not value)
  • Counseling for nutrition
  • Counseling for physical activity

 

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

 

Code services correctly to measure success

These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:

 

Description

CPT®

ICD-10-CM

HCPCS

BMI percentile

 

Z68.51-Z68.54

 

Counseling for nutrition

97802, 97803, 97804

Z71.3

G0270, G0271, G0447, S9449, S9452, S9470

Counseling for physical activity

 

Z02.5, Z71.82

G0447, S9451

 

Codes to identify outpatient visits

 

CPT®

HCPCS

99201-99205,
99211-99215,
99241-99245,
99341-99345,
99347-99350,
99381-99387,
99391-99397,
99401-99404,
99411, 99412, 99429, 99455, 99456, 99483

 

G0402, G0438, G0439, G0463, T1015

 

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

 

American Academy of PediatricsAmerican Academy of Pediatrics raises concern about children’s nutrition and physical activity during pandemic. Available at:

http://services.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/. Accessed December 10, 2020.

1 https://pediatrics.aappublications.org/content/147/5/e2021050123?cct=2287#F1

 

1232-0721-PN-CNT

AdministrativeCommercialJuly 1, 2021

Proper coding for in-home monitoring can make a measurable difference for INR

It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier! Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.

 

Self-testing: Measurable difference when correct coding is reflected

This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it. Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.

 

Value set ID and subgroup

Code

Description

INR Home Monitoring

CPT code 93792

Patient/caregiver training for initiation of home INR monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results.

INR Home Monitoring

CPT code 93793

Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab INR test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.

INR Home Monitoring

HCPCS code G0248

Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results.

INR Home Monitoring

HCPCS code G0249

Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include four tests.

INR Home Monitoring

HCPCS code G0250

Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include four tests.


INR clinical quality measure

The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

Clinical Quality Measure

Required documentation

CPT, HCPCS, LOINC and
CPT Performance Codes

Provider Specialty

INR Monitoring for Individuals on Warfarin*

Adults 18 years of age and older who have had at least one 56- day interval of warfarin therapy and received at least one INR monitoring test during each 56-day interval with active warfarin therapy in the measurement year. Excludes patients who are monitoring INR at home during the treatment period

-CPT 85610 Prothrombin time

-LOINC 34714-6 INR blood by coagulation assay

-6301-6 INR in platelet poor plasma by coagulation assay

-38875-1 INR in platelet poor plasma or blood by coagulation assay

-46418-0 INR in capillary blood by coagulation assay

-52129-4 INR in platelet poor plasma by coagulation - post heparin adsorption

 

Excludes:

-G0248 Demonstrate use home INR monitoring

-G0249 Provide test materials and equipment for home INR monitoring

-G0250 Physician INR test review interpretation and management

No provider type restrictions


1231-0721-PN-CNT

AdministrativeCommercialJuly 1, 2021

Timely receipt of primary payer’s EOB can help reduce timely filing denials for secondary claims

Many members have both primary and secondary insurance policies, and it’s important to know which policy is primary. We want to make it as easy as possible for you to find out so you can avoid claim denials for  not filing the secondary claim within the timely filing guidelines.

 

Before the member arrives for their appointment, check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for their appointment. After providing services, submit the member’s claim as usual – you can use Availity for that, too, through the Claims & Payments app.

 

If we are the secondary payer, we will need the explanation of benefits (EOB) from the primary carrier along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.

 

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claim system will deny the claim because we don’t have the EOB. This can cause a delay in receipt of your  payment and can even cause you to miss the timely filing guideline.

 

We want you to have of the information you need to know the very best way to file your claims. For more information about filing claims, visit anthem.com > Provider > Claims Submissions. For help using Availity, log onto availity.com and select the Help & Training tab.

 

1234-0721-PN-CNT

Digital SolutionsCommercialJuly 1, 2021

Interactive Care Reviewer (ICR): New search option for cases submitted through ICR

Locating a case using Interactive Care Reviewer (ICR), Anthem Blue Cross and Blue Shield (Anthem) digital authorization tool just got easier. We added the ICR Case Search tab within the tool so you can find cases submitted through ICR. Cases submitted through both ICR and other sources can still be located using the other search options: Member, Date Range, Reference/Authorization Request Number or Discharge Date.

 

The steps to access ICR through the Availity Portal have not changed. You are required to have the Authorization & Referral Request role or the Authorization & Referral Inquiry role. Your organization’s Availity administrator can assign these roles.

  1. Log onto Availity’s home page with your unique user ID and password
  2. Select Patient Registration
  3. Select Authorizations & Referrals
  4. Select Authorization Inquiry
  5. Choose the Payer and Organization
  6. Accept the ICR Disclaimer
  7. Select Check Case Status from the ICR navigation bar

 

Here is what’s new:

The ICR Inquiry dashboard displays the new ICR Case Search tab. This new option is currently available for users who have the Authorization & Referral Request role. Users with the Authorization & Referral Inquiry role will be able to access the ICR Case Search tab in mid-July. Until then, the additional search options are available.

 

To locate a case submitted through ICR, select the ICR Case Search tab then choose the criteria to complete your search.

 

Use the additional search options to find cases submitted through both ICR and other sources.

 

Register for our monthly new user ICR webinar to learn about basic navigation and features: ICR Webinar Registration

 

Or you can visit the Custom Learning Center located on Availity Payer Spaces to access ICR navigation demonstrations and reference guides.

 

1233-0721-PN-CNT

Digital SolutionsCommercialJuly 1, 2021

Electronic claim response files

Anthem Blue Cross and Blue Shield (Anthem) uses Availity as its exclusive partner for managing all electronic data interchange (EDI) transactions.

 

When your organizations claims are submitted either by your clearinghouse/vendor or submitted directly using practice management software, it’s important to review and utilize all responses to understand where your claims are in the adjudication process and if any action is required.

 

Below is a summary of the process for electronic files, and the response reports that are returned by Availity:

 

Electronic File is submitted to Availity

  • Availity acknowledges receipt of file and validates for X12 format in a series of responses.
  • The series of initial responses indicate whether an electronic file was successfully received in correct format and accepted by Availity.
  • If errors occur, the impacted file will require resubmission to Availity.
  • If your organization uses a clearinghouse/vendor, they are responsible for reviewing these response files.

 

HIPAA and Business Validation

  • Electronic Batch Report (EBR) – This response acknowledges accepted claims and identifies claims with a HIPAA and business edits prior to routing for adjudication.
  • Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the 835 Electronic Remittance Advice. (Edit examples include - Invalid subscriber ID for the date of service and invalid billing and coding per industry standards)
  • Clearinghouse/vendors may provide their own version of this report to your organization.

 

Availity Routes Claims to Payer Anthem

  • Delayed Payer Report (DPR) – This response file contains an additional level of editing by the membership adjudication system.
  • Currently this response only returns for the Medicare/ Medicaid lines of business.
  • The Commercial lines will return this response in the future, look for forthcoming communications with the details.
  • Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the 835 Electronic Remittance Advice.
  • Clearinghouses/vendors may provide their own version of this report to your organization.

 

If you have further questions on the response reports, please contact Availity

at 1-800-282-4548.

 

1203-0721-PN-CNT

Digital SolutionsCommercialJuly 1, 2021

How to enroll in electronic fund transfer (EFT) for faster remittance

Like the payroll direct deposit service that most businesses offer their employees, electronic funds transfer (EFT) is a digital payment solution that uses the automated clearinghouse (ACH) network to transmit health care payments from a health plan to a health care provider’s bank account. Health plans can use a provider’s banking information only to deposit funds, not to withdraw funds.

 

Anthem Blue Cross and Blue Shield (Anthem) expects providers to accept payment via EFT in lieu of paper checks. Providers can register or manage account changes for EFT via the CAQH enrollment tool called EnrollHub™. This tool will help eliminate the need for paper registration, reduce administrative time and costs and allows physicians and facilities to register with multiple payers at one time. By eliminating paper checks, EFT payments are deposited directly into your account faster.

 

Read more about going digital with Anthem in the Provider Digital Engagement Supplement available online. Go to anthem.com, select Providers, under the Provider Resources heading select Forms and Guides. Select your state if you haven’t done so already. From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.

 

1172-0721-PN-CNT

Medical Policy & Clinical GuidelinesCommercialJuly 1, 2021

Reminder: Updated AIM rehabilitative program effective August 1, 2021 - Site of service reviews

As previously communicated in the May 2021 edition of Provider News, effective August 1, 2021, AIM Specialty Health® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity reviews of the requested site of service for physical, occupational and speech therapy procedures for Anthem Blue Cross and Blue Shield (Anthem) fully insured members.

 

AIM will require prior authorization for all outpatient facility and office-based rehabilitative and habilitative services. Prior authorization is recommended for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and ensure the member is receiving care at the appropriate site of service early in the process. After the evaluation, ongoing services will be subject to site of care review and require prior authorization, including post service review which may result in a denial of coverage as not medically necessary for the site of care. Requests that are not medically necessary at a hospital site may be approved for coverage at a free standing or office-based setting.

 

AIM will use the following Anthem Clinical UM Guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. The clinical criteria to be used for these reviews can be found on the Anthem Provider portal Clinical UM Guidelines page. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, services with diagnosis of autism, and members ages birth to 3rd birthday.

 

AIM will begin accepting prior authorization requests on July 19, 2021 for services provided on or after August 1, 2021. Prior authorization requests may be submitted via the AIM’s ProviderPortalSM directly at providerportal.com or by calling 800-554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. ET.

 

AIM rehabilitation educational information

The AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists and CPT code lists. Anthem also invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM.  Go to the AIM Rehabilitation microsite to access helpful information and register for an upcoming webinar on July 8 or July 27 at 3 p.m. ET. If you have previously registered for other services managed by AIM, there is no need to register again.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

1209-0721-PN-IN.KY.MO.OH

Medical Policy & Clinical GuidelinesCommercialJuly 1, 2021

Medical Policy and Clinical Guideline Updates - July 2021*

The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on May 13, 2021 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

Determine if prior authorization is needed for an Anthem member by going to anthem.com > select “Providers” > under “Claims” > select “Prior Authorization”, then select your state. Or, you may call the prior authorization phone number on the back of the member’s ID card.

 

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit fepblue.org > Policies & Guidelines.

 

Below are the new medical policies that have been approved.

 

Title

Information

Effective date

GENE.00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

• The use of gene expression profiling to assist in the diagnosis or management of idiopathic pulmonary fibrosis is considered investigational and not medically necessary (INV&NMN) in all situations

10/1/2021

LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline

• Use of a machine learning derived probability score (e.g., KidneyIntelX) to predict rapid kidney function decline in chronic kidney disease is considered INV&NMN for all indications
• Existing CPT PLA code 0105U will be considered INV&NMN

10/1/2021

MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion

• Eye movement analysis using non-spatial calibration is considered INV&NMN for the diagnosis of concussion
• Existing CPT Category III code 0615T will be considered INV&NMN

10/1/2021

CG-MED-89

Home Parenteral Nutrition

• Outlines the MN and NMN criteria for initial and continuing use of home parenteral nutrition

-Existing codes B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9004, B9006, B9999, S9364, S9365, S9366, S9367, S9368 for parenteral nutrition will be reviewed for MN criteria

11/1/2021

 

The current clinical guidelines and/or medical policies listed below were reviewed and updates were approved.

 

Note:  *Prior authorization required

Title

Change

Effective date

*CG-SURG-27 Gender Affirming Surgery

 

Previously titled: Gender Reassignment Surgery

 

• Revised title

• Replaced the word 'reassignment' with the word 'affirming' in title and throughout document

• Alphabetized procedures in MN statements

• Revised gender dysphoria criteria in all MN statements

• Added “or intolerance” to hormone therapy related criteria

• Clarified hair removal MN statement

• Moved bilateral mastectomy and nipple reconstruction from MN to REC section

• Added breast augmentation and breast reduction to REC section and reframed procedures as "gender affirming chest procedures"

• Moved gender affirming facial surgical procedures from cosmetic and not medically necessary (COS&NMN) to REC section

• Moved voice modification surgery from COS&NMN to reconstructive (REC) section

• Removed voice therapy from scope of document

• Clarified the NMN and the COS&NMN statements to reflect changes listed above

• Revised the Further Considerations statement to include all gender affirming chest procedures
• Added CPT codes for urethroplasty (pelvic surgery); added facial reconstructive procedures including rhinoplasty, fat grafting, collagen injections, liposuction, and NOC code for thyroid cartilage chondroplasty; added NOC code for voice modification surgery; added liposuction and fat grafting as chest procedures

5/20/2021

MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

• Added electrical impedance spectroscopy for the evaluation of skin lesions as INV&NMN
• Added CPT category III code 0658T effective 07/01/2021 for electrical impedance spectroscopy; considered INV&NMN

10/1/2021

*OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis

• Revised medical necessity (MN) criteria for microprocessor controlled lower limb prosthesis

• Added microprocessor controlled foot or ankle systems as MN when criteria are met

• Clarified INV&NMN statement addressing microprocessor controlled foot-ankle prosthesis

• HCPCS code L5973 for microprocessor controlled ankle-foot system will be reviewed for MN criteria (was INV&NMN)

5/20/2021

*SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

• Added hypoglossal nerve stimulation as MN when criteria are met

• Revised NMN and INV&NMN statements 

• CPT category III codes 0466T, 0467T, 0468T for hypoglossal nerve stimulators and related nonspecific codes 64568, C1767, C1778, C1787, L8680, L8681, L8688 will be reviewed for MN criteria for obstructive sleep apnea (OSA) diagnoses (were INV&NMN)

5/20/2021

SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy

• Added the use of perirectal spacers during prostate radiotherapy as MN when criteria are met

• Revised INV&NMN statement

• CPT code 55874 will be reviewed for MN criteria for prostate cancer diagnoses (was INV&NMN)

5/20/2021

*TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

• Added a single autologous (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation as MN for the treatment of relapsing-remitting multiple sclerosis when criteria are met.

• Added a single autologous (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplant as INV&NMN for the treatment of multiple sclerosis when the MN criteria are not met, including for primary progressive or secondary progressive forms of multiple sclerosis

• Added a repeat autologous (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplant as INV&NMN for the treatment of relapsing-remitting multiple sclerosis.

• Added an allogeneic (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation, or planned tandem as INV&NMN for the treatment of multiple sclerosis.

• Revised INV&NMN statement for all other autoimmune diseases

• CPT codes 38206, 38232, 38241 and related non-specific CPT and ICD-10-PCS codes for autologous HSCT will be reviewed for diagnosis G35 multiple sclerosis for MN criteria (were INV&NMN)

5/20/2021

*CG-DME-49

Standing Frames

• Content moved from DME.00034

• No change to Clinical Indications

10/1/2021



1201-0721-PN-CNT

Reimbursement PoliciesCommercialJuly 1, 2021

Reimbursement policy update: Consultations - Professional*

Beginning with dates of service on or after October 1, 2021, Anthem Blue Cross and Blue Shield (Anthem)’s current Documentation and Reporting Guidelines for Consultations will be renamed Consultations. This policy aligns with CMS guidance, does not allow reimbursement for inpatient (99251-99255) and outpatient (99241-99245) consultation codes and requires providers to bill the appropriate office visit E/M code for consultation services.

 

For more information about this policy, visit the reimbursement policy page on anthem.com.

 

1226-0721-PN-CNT

Reimbursement PoliciesCommercialJuly 1, 2021

New reimbursement policy: Non-patient laboratory services - Facility*

Beginning with dates of service on or after October 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will implement a new reimbursement policy titled Non-Patient Laboratory Services. Anthem does not allow reimbursement for non-patient laboratory services when reported on a UB-04 with bill type 014X unless provider, state, federal or CMS and/or requirements indicate otherwise.

 

For more information about this policy, visit the reimbursement policy page on anthem.com.

 

1225-0721-PN-CNT

Products & ProgramsCommercialJuly 1, 2021

Reminder: Back Pain Guide program effective July 19, 2021

As previously communicated in the June 2021 edition of Provider News, effective July 19, 2021, Anthem Blue Cross and Blue Shield (Anthem), and AIM Specialty Health® (AIM), a separate specialty benefits management company, will launch a new Back Pain Guide program for Anthem fully insured members. The new Back Pain Guide program will identify members that are experiencing back pain or are at risk for complications related to back pain conditions and help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.

 

Our targeting management process includes:

  • Predictive models for members likely to be referred for back surgery based on several risk factors
  • Risk stratification to ensure the appropriate level of support is provided
  • Targeted outreach to members through our digital engagement platform, email and calls
  • Customized education and support of provider treatments based on member’s specific needs
  • Education about the availability of supportive services such as behavioral health as appropriate

 

AIM Back Pain Program Educational Information

The AIM Back Pain Guide Program microsite helps you learn more and access helpful information and tools such as program information and FAQs. Anthem also invites you to take advantage of a free informational webinar that will introduce you to the programGo to the AIM Back Pain Guide Program microsite to access helpful information and register for an upcoming webinar.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

1211-0721-PN-IN.KY.OH

Products & ProgramsCommercialJuly 1, 2021

Company to retire Blue Precision program at the end of the year

For more than a decade, Blue Precision, the Anthem Blue Cross and Blue Shield (Anthem) physician transparency program, has recognized specialists for meeting or exceeding established quality and cost effectiveness measures. Thank you to all those physicians participating in our networks and for the care you provide to our members.

 

Anthem is announcing that we have made the decision to retire our Blue Precision program effective December 31, 2021. Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.

 

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare.

 

1202-0721-PN-IN.KY.MO.OH.

PharmacyCommercialJuly 1, 2021

Certain specialty medication prior authorization requests may require additional documentation*

As part of our ongoing quality improvement efforts, Anthem Blue Cross and Blue Shield (Anthem) is updating our prior authorization processes for certain specialty medications. Effective August 1. 2021, we may request additional documentation for impacted medications to determine medical necessity.

 

Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.

 

Should you have any questions, please refer to the Clinical Criteria policy website for specific medication criteria details, including documentation requirements.

 

Impacted Policy

Impacted Medication(s)

ING-CC-0153: Adakveo (crizanlizumab)

Adakveo

ING-CC-0065: Agents for Hemophiilia A and von Willebrand Disease

Advate, Adynovate, Afstyla, Alphanate, Eloctate, Esperoct, Helixate FS, Hemlibra, Hemofil-M, Humate-P, Jivi, Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha

ING-CC-0148: Agents for Hemophilia B

Alphanine SD, Alprolix, Bebulin, Benefix, Idelvion, Ixinity, Mononine, Profilnine SD, Rebinyn, Rixubis

ING-CC-0025: Aldurazyme (laronidase)

Aldurazyme

ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

ING-CC-0028: Benlysta (belimumab)

Benlysta

ING-CC-0012: Brineura (cerliponase alfa)

Brineura

ING-CC-0137: Cablivi (caplacizumab-yhdp)

Cablivi

ING-CC-0041: Complement Inhibitors

Soliris, Ultomiris

ING-CC-0081: Crysvita (burosumab-twza)

Crysvita

ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)

Duopa

ING-CC-0029: Dupixent (dupilumab)

Dupixent

ING-CC-0069: Egrifta (tesamorelin)

Egrifta

ING-CC-0024: Elaprase (idursufase)

Elaprase

ING-CC-0173: Enspryng (satralizumab-mwge)

Enspryng

ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

ING-CC-0044: Exondys 51 (eteplirsen)

Exondys 51

ING-CC-0021: Fabrazyme (agalsidase beta)

Fabrazyme

ING-CC-0068: Growth hormone

Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive

ING-CC-0034: Hereditary Angioedema Agents

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

ING-CC-0188: Imcivree (setmelanotide)

Imcivree

ING-CC-0070: Jetrea (ocriplasmin)

Jetrea

ING-CC-0037: Kanuma (sebelipase alfa)

Kanuma

ING-CC-0057: Krystexxa (pegloticase)

Krystexxa

ING-CC-0018: Lumizyme (alglucosidase alfa)

Lumizyme

ING-CC-0013: Mepsevii (vestronidase alfa)

Mepsevii

ING-CC-0043: Monoclonal Antibodies to Interleukin-5

Cinqair, Fasenra, Nucala

ING-CC-0023: Naglazyme (galsulfase)

Naglazyme

ING-CC-0111: Nplate (romiplostim)

Nplate

ING-CC-0082: Onpattro (patisiran)

Onpattro

ING-CC-0077: Palynziq (pegvaliase-pqpz)

Palynziq

ING-CC-0049: Radicava (edaravone)

Radicava

ING-CC-0156: Reblozyl (luspatercept)

Reblozyl

ING-CC-0159: Scenesse (afamelanotide)

Scenesse

ING-CC-0149: Select Clotting Agents for Bleeding Disorders

Feiba, Novoseven

ING-CC-0079: Strensiq (asfotase alfa)

Strensiq

ING-CC-0008: Subcutaneous Hormonal Implants

Testopel

ING-CC-0084: Tegsedi (inotersen)

Tegsedi

ING-CC-0162: Tepezza (teprotumumab-trbw)

Tepezza

ING-CC-0170: Uplizna (inebilizumab)

Uplizna

ING-CC-0172: Viltepso (viltolarsen)

Viltepso

ING-CC-0022: Vimizim (elosulfase alfa)

Vimizim

ING-CC-0152: Vyondys 53 (golodirsen)

Vyondys 53

ING-CC-0017: Xiaflex (clostridial collagenase histolyticum) injection

Xiaflex

ING-CC-0033: Xolair (omalizumab)

Xolair

 

1204-0721-PN-CNT

PharmacyCommercialJuly 1, 2021

Updates for specialty pharmacy are available - July 2021*

Prior authorization updates

 

Effective for dates of service on and after October 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Access the Clinical Criteria information.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0195

J3490

J9999

C9399

J3590

Abecma

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Step therapy updates

 

Effective for dates of service on and after October 1, 2021, 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. 

 

Access the Clinical Criteria information.

 

Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

HCPCS Code

Status

Drug(s)

ING-CC-0020

J2323

Non-preferred

Tysabri

 

1221-0721-PN-CNT

PharmacyCommercialJuly 1, 2021

Designated specialty pharmacy network updates effective October 1, 2021*

As we previously communicated, Anthem Blue Cross and Blue Shield (Anthem)’s Designated Specialty Pharmacy Network requires providers who are not part of the Designated Specialty Pharmacy Network to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through CVS Specialty Pharmacy.

 

This update is to advise of the following changes:

 

Effective for dates of service on and after October 1, 2021, the following specialty pharmacy medications will be added to the Designated Medical Specialty Pharmacy drug list. Accordingly, hospitals that are not in the Designated Specialty Pharmacy Network will be required to acquire these specialty medications administered in the hospital outpatient setting from CVS Specialty Pharmacy.

 

HCPCS

Description

Brand Name

Q5117

INJECTION, TRASTUZUMAB-ANNS, BIOSIMILAR 10MG

Kanjinti

J1558

INJECTION, IMMUNE GLOBULIN 100MG

Xembify

Q5123

INJECTION, RITUXIMAB-ARRX, BIOSIMILAR

Riabni

 

To access the current Designated Medical Specialty Pharmacy drug list, please visit anthem.com, select Providers, select Forms and Guides (under the Provider Resources column), select your state, scroll down and select Pharmacy in the Category drop down. The Designated Medical Specialty Pharmacy drug list may be updated periodically by Anthem.

 

If you have questions or would like to discuss the terms and conditions to be included as a Designated Specialty Pharmacy Network provider, please contact your Anthem Contract Manager. Thank you for your continued participation in the Anthem networks and the services you provide to our members.

 

1227-0721-PN-IN.WI

PharmacyCommercialJuly 1, 2021

Update: Site of care medical necessity reviews for long-acting colony-stimulating factors not implemented on June 1, 2021*

This is an update to the article published in the March 2021 edition of Provider News regarding Site of Care medical necessity reviews for long-acting colony-stimulating factors effective June 1, 2021.

This program was not implemented on June 1, 2021, and it will not be implemented.

 

Medical necessity review of the site of care for the following long acting colony-stimulating factors for oncology indications will not be required as originally communicated.  

  • Neulasta® and Neulasta Onpro® (pegfilgrastim)
  • Fulphila® (pegfilgrastim-jmdb)
  • Udenyca® (pegfilgrastim-cbqv)
  • Ziextenzo® (pegfilgrastim-bmez)
  • Nyvepria™ (pegfilgrastim-apgf)

 

There have been no changes for ordering providers who submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021.

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services. If you have questions, please call the Provider Service phone number on the member’s ID card.  

 

1210-0721-PN-CNT

State & FederalMedicare AdvantageJuly 1, 2021

New reimbursement policy: Modifier 90: Reference (outside) laboratory and pass-through billing

Effective October 1, 2021, Anthem Blue Cross and Blue Shield does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate.

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at anthem.com/medicareprovider.

 

ABSCRNU-0212-21

State & FederalMedicare AdvantageJuly 1, 2021

Prior authorization requirement changes for codes A0426 and A0428 effective October 1, 2021

Effective October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Anthem Blue Cross and Blue Shield. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these prior authorization rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added for the following codes:

  • A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
  • A0428 — ambulance service, basic life support, nonemergency transport (BLS)

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at availity.com or on the provider website at anthem.com/medicareprovider > Login. Contracted and non-contracted providers unable to access Availity can call the Provider Services located on the back of their patient’s member ID card for PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0232-21

State & FederalMedicare AdvantageJuly 1, 2021

Medical drug benefit clinical criteria updates

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield and AMH Health, LLC. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or would like 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 members of 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.

 

Effective date

Document number

Clinical Criteria title

New or revised

July 16, 2021

ING-CC-0195*

Abecma (idecabtagene vicleucel)

New

July 16, 2021

ING-CC-0191*

Pepaxto (melphalan flufenamide; melflufen)

New

July 16, 2021

ING-CC-0192*

Cosela (trilaciclib)

New

July 16, 2021

ING-CC-0193*

Evkeeza (evinacumab)

New

July 16, 2021

ING-CC-0194*

Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

New

July 16, 2021

ING-CC-0125

Opdivo (nivolumab)

Revised

July 16, 2021

ING-CC-0064

Interleukin-1 Inhibitors

Revised

July 16, 2021

ING-CC-0159*

Scenesse (afamelanotide)

Revised

July 16, 2021

ING-CC-0151

Yescarta (axicabtagene ciloleucel)

Revised

July 16, 2021

ING-CC-0145*

Libtayo (cemiplimab-rwlc)

Revised

July 16, 2021

ING-CC-0130*

Imfinzi (durvalumab)

Revised

July 16, 2021

ING-CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

July 16, 2021

ING-CC-0075*

Rituximab Agents for Non-Oncologic Indications

Revised

 

ABSCRNU-0233-21

State & FederalMedicare AdvantageJuly 1, 2021

Let’s Vaccinate

Help increase your vaccination rates and close gaps-in-care with these tools and strategies

 

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

 

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

  • Address disparities for vaccine-preventable diseases.
  • Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
  • Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
  • Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

 

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

 

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

 

ABSCRNU-0228-21

State & FederalMedicare AdvantageJuly 1, 2021

Medicare News - July 2021

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Member Rights and Responsibilities Statement

The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Member Rights and Responsibilities Statement.

 

The Member Rights and Responsibilities Statement is located within the provider manual.

 

AIN-NU-0289-21

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at anthem.com/provider/policies/clinical-guidelines/search/.

 

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the numbers listed below. You can access UM criteria online at the web address listed above.

 

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept prior authorization requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.

 

You can submit prior authorization requests by:

  • Calling us at:
    • Hoosier Healthwise: 866‑408‑6132
    • Healthy Indiana Plan: 844‑533‑1995
    • Hoosier Care Connect: 844‑284‑1798
  • Faxing us at:
    • Inpatient medical fax: 866-406-2803
    • Outpatient medical fax: 866-406-2803
    • Pharmacy fax (retail): 844-864-7860
      • Medical injectable: 888-209-7838
    • Behavioral health inpatient fax: 844-452-8074
    • Behavioral health outpatient fax: 844-456-2698
  • Submitting online at:

 

Have questions about utilization decisions or the UM process?

Call our Provider Helpline at the numbers below Monday through Friday from 8 a.m. to 8 p.m.:

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

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

AIN-NU-0286-21

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Complex Case Management program

Managing illness can be a daunting task for our members. It is not always easy to understand test results, know how to obtain essential resources for treatment, or who to contact with questions and concerns.

 

Anthem Blue Cross and Blue Shield is available to offer assistance in these difficult moments with our Complex Case Management program. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, PMPs, and caregivers. The complex case management process uses the experience and expertise of the Case Coordination team to educate and empower our members by increasing self-management skills. It can also help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare.

 

Members or caregivers can refer themselves or family members by calling the Member Services number located on the back of their ID card. They will be transferred to a care manager based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

 

You can contact us by phone at:

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

 

Case Management business hours are Monday through Friday from 8 a.m. to 5 p.m. Eastern time.

 

The Case Management team provides the following services:

  • Assist members in establishing a medical, dental, or behavioral health home, and educate on value of prevention and wellness.
  • Provide education to members with a new diagnosis and support them in acquiring prescribed medical equipment to support their treatment plan.
  • Assist members with smoking cessation/reduction through education and connection to local resources to achieve healthier living.
  • Provide support, education, and resources to high-risk OB populations to support the reduction of infant mortality, prematurity, and low birthweight.
  • Assess for desire and readiness to connect our non-English speaking population to ESL classes and other support resources to enhance their cultural experience in Indiana.

 

Case Management is a member centric program, which promotes autonomy, healthy living, ease of utilizing their benefits, and much more.

 

AIN-NU-0285-21

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

New reimbursement policy: Modifier 90: Reference (outside) laboratory and pass-through billing

Effective October 1, 2021, Anthem Blue Cross and Blue Shield does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at anthem.com/inmedicaiddoc.

 

AIN-NU-0266-21

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Provider education program survey: Your Voice Counts

To provide you with better educational opportunities, we are collecting data to improve provider education offerings. We are also asking for preferences and topics of interest to ensure that we tailor the education experience to meet your needs. We value our providers, and we want to deliver educational content that is most convenient for you. Please take a moment to complete a brief survey, and remember — Your voice counts! 

 

Select the survey below to begin:

Provider education: Your Voice Counts

 

AIN-NU-0257-20

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Continuing medical education/continuing education unit opportunities

We offer webinars on a variety of topics, including medical coding, claims issues, quality measures, healthcare and more. Each live webinar may offer both continuing medical education (CME)/continuing education unit (CMU) credit for attendees. On-demand recordings are also available (with CME credit) for your convenience.

 

Sign up for a session here today!

 

AIN-NU-0097-21

State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJuly 1, 2021

Medicaid News - July 2021