 Provider News IndianaJuly 2021 Anthem Provider News - Indiana Contents State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 Medicaid News - July 2021
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!
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 Pediatrics. American 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
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
|
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.
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.
- Log onto Availity’s home page with your unique user ID and password
- Select Patient Registration
- Select Authorizations & Referrals
- Select Authorization Inquiry
- Choose the Payer and Organization
- Accept the ICR Disclaimer
- 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.
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.
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.
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.
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
|
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.
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.
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 program. Go 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.
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.
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)
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Onpattro
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ING-CC-0077: Palynziq (pegvaliase-pqpz)
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Palynziq
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ING-CC-0049: Radicava (edaravone)
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Radicava
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ING-CC-0156: Reblozyl (luspatercept)
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Reblozyl
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ING-CC-0159: Scenesse (afamelanotide)
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Scenesse
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ING-CC-0149: Select Clotting Agents for Bleeding Disorders
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Feiba, Novoseven
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ING-CC-0079: Strensiq (asfotase alfa)
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Strensiq
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ING-CC-0008: Subcutaneous Hormonal Implants
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Testopel
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ING-CC-0084: Tegsedi (inotersen)
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Tegsedi
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ING-CC-0162: Tepezza (teprotumumab-trbw)
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Tepezza
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ING-CC-0170: Uplizna (inebilizumab)
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Uplizna
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ING-CC-0172: Viltepso (viltolarsen)
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Viltepso
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ING-CC-0022: Vimizim (elosulfase alfa)
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Vimizim
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ING-CC-0152: Vyondys 53 (golodirsen)
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Vyondys 53
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ING-CC-0017: Xiaflex (clostridial collagenase histolyticum) injection
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Xiaflex
|
|
ING-CC-0033: Xolair (omalizumab)
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Xolair
|
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).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
|
|
*ING-CC-0195
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J3490
J9999
C9399
J3590
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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).
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Clinical Criteria
|
HCPCS Code
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Status
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Drug(s)
|
|
ING-CC-0020
|
J2323
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Non-preferred
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Tysabri
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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.
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HCPCS
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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.
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.
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.
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.
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
|
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.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 Member Rights and Responsibilities StatementThe 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.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 Important information about utilization managementOur 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
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 Complex Case Management programManaging 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.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 New reimbursement policy: Modifier 90: Reference (outside) laboratory and pass-through billingEffective 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.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 Provider education program survey: Your Voice CountsTo 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
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 Continuing medical education/continuing education unit opportunitiesWe 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!
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 1, 2021 Medicaid News - July 2021 |