 Provider News IndianaMay 2021 Anthem Provider News - Indiana Contents State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | May 1, 2021 Medicaid news - May 2021
New prior authorization requirements for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.
Changes to Prior Authorization Requirements:
- Updates for specialty pharmacy are available*
- New prior authorization requirement: Kidney transplantation*
- Updated AIM rehabilitative program effective August 1, 2021 – Initial evaluations and site of service reviews*
- Reimbursement policy update: Claims requiring additional documentation – Facility*
Amendment for Indiana Providers
Updated Provider Manual posted to anthem.com
We want to make you aware of upcoming changes to the Indiana Anthem Blue Cross and Blue Shield (Anthem) Provider Manual.
This update to the Anthem Blue Cross and Blue Shield Base Provider Agreement, will replace the current Provider Manual with the updated Provider Manual, effective July 1, 2021.
We have posted the updated Provider Manual to the public provider website at anthem.com. To view the new manual, visit anthem.com, select Provider, and select the Policies, Guidelines & Manuals. Select Indiana followed by Provider Manual Download the Manual or click here.
If you have questions, please contact your local Professional Provider Network Contractor at 1-800-455-6805.
We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well. The current health crisis illuminates this quite clearly. It is imperative to offer care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield is committed to supporting our providers in this effort.
MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:
- Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers to enhance care.
- Real life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.
While there is no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.
Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.
My Diverse Patients
Stronger Together Health Equity Resources
Often, healthcare costs incurred by Anthem Blue Cross and Blue Shield (Anthem) members are a result of recommendations made by their physicians. As an Anthem participating physician, you have the ability to help reduce your patients’ healthcare costs. Choices, such as where to refer a member for negative pressure wound therapy, can have a significant impact on your patients’ ultimate out-of-pocket liability. We are sharing the following information with you for consideration when referring patients for negative pressure wound therapy.
Our members, your patients, often participate in health benefit plans that may have coinsurance or deductibles. Your patients may experience significant differences in cost depending on which negative pressure wound therapy providers the members are referred to. The following table provides a sample listing of Anthem high quality, low cost national negative pressure wound therapy providers. Referring to these providers will likely lower your patients’ out-of-pocket costs.
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Provider
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Phone Number
|
|
Apria
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1-800-780-1228
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|
Rotech
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1-844-592-5068
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You can find all of Anthem’s participating durable medical equipment (DME) orthotics and prosthetics providers, at Find Care, Anthem’s doctor finder and transparency tool, at anthem.com.
Anthem is committed to seeking ways to reduce healthcare costs, and your referrals to network- participating providers can help make a difference. We appreciate your partnership in considering the financial impact to your patients – our members – especially during these challenging economic times.
If you have questions, please contact your local Network Relations Consultant or call Provider Services.
All associates who make utilization management decisions are required to adhere to the following principles:
- Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
- We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support denials of benefits.
- Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization, or create barriers to care and service.
The American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care. Known as the “periodicity schedule,” this screenings and assessments guideline provides a comprehensive schedule for each well-child visit, from infancy.
Schedule for well-child visits
The AAP recommends that children should have a total of eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure. Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures.
Complete coverage for well-child visits regardless of when visit is received
Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.
HEDIS® measures W30 and WCV
Well-child visits in the first 30 months of life (W30)
Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:
- Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
- Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.
Child and adolescent well-care visits
Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
A WISEWOMANTM knows that improving blood pressure is good for the heart
In honor of National High Blood Pressure Education Month, learn more about CDC’s WISEWOMAN program: Well-Integrated Screening and Evaluation for WOMen Across the Nation.
The aim of this program is to improve the delivery of heart disease and stroke prevention services for underserved women, aged 40-64 years. The program focuses on cardiovascular disease risk factors, specifically improving high blood pressure.1 To learn even more about WISEWOMAN, visit the CDC website.
Resources for your Patients
If your patient is one of the tens of millions of American adults who have hypertension, you know encouraging a healthier lifestyle and prescribing the right medications is important to managing the condition. But, if you would like to provide additional information about high blood pressure to your patients, take advantage of the helpful resources available to healthcare professionals through the CDC.
Meeting the HEDIS® measure?
Controlling High Blood Pressure (CBP) assesses adults ages 18-85 with a diagnosis of hypertension and whose blood pressure was properly controlled base on the following criteria
- Adults 18-59 years of age whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg
Patient claims should include one systolic reading and one diastolic reading2:
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CPT II Code
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Most recent systolic blood pressure
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|
3074F
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<130 mm Hg
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|
3075F
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130-139 mm Hg
|
|
3077F
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≥ 140 mm Hg
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|
CPT II Code
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Most recent diastolic blood pressure
|
|
3078F
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<80 mm Hg
|
|
3079F
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80-89 mm Hg
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|
3080F
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≥ 90 mm Hg
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When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.
Additional tips for talking to patients
- Continue to educate patients about the risks of hypertension
- Encourage weight loss, regular exercise, and diet
- Advise patients who are smoking to quit
- Talk about chronic stress and ways to cope with it in a healthy way
1https://www.cdc.gov/wisewoman/about.htm
2https://www.cdc.gov/bloodpressure/index.htm
The Appointment Scheduler application in Availity Payer Spaces is an online appointment-scheduling feature that allows providers to manage appointments with patients that may want to schedule appointments directly. Providers can manage patients’ appointment requests and maintain their appointment availability.
Providers can receive new appointment requests from active members, along with important information like the member’s ID number, contact information and any special health information they want the doctor to know. Providers can modify or deactivate their availability at any time. Availity users with the role of “Office Staff” can set up physicians in the practice to accept online appointment requests.
Enrollment for Appointment Scheduler is easy. To access Appointment Scheduler in the Availity portal: Availity > Payer Spaces > Select Payer Tile > Applications
Appointment Scheduler features:
- Manage appointment requests and view physician availability
- Configure appointment availability
- Notification of new visit requests on Availity Notification Center and via email
- Members are notified directly via text or email once appointment is confirmed
- Send patient reminders via the Appointment Scheduler application
- Customize office locations and available times, as well as the types of appointments accepted
Visit the Appointment Scheduler application in the Availity portal today.
Our organization is working robustly to establish Anthem Blue Cross and Blue Shield (Anthem) as a digital-first enterprise and to streamline your daily working tasks by using electronic functionalities. In support of the Digital-First Solutions we are excited to publish two Provider Bulletins about submitting medical attachments and itemized bills in partnership with Availity.
The objective of the bulletins is to provide a simple guide for you and your staff with step-by-step navigation instructions, where to find help and training with medical attachments.
The provider bulletins are posted on the Custom Learning Center (CLC) under the Resources tab. Follow these steps to access the helpful documents:
- Availity > Payer Spaces > Select Payer Tile > Applications > Custom Learning Center > Select Catalog > Resources to locate, view or download the Provider Bulletins
Please encourage your staff who have questions on the process or who are not submitting claim attachments electronically to review these valuable resources for assistance.
After receiving your feedback, we expanded our server to meet your need to upload larger files to our digital attachment tool, through Availity. You can now upload files up to 100 megabytes, eliminating the need to mail or fax.
Use the attachment tool to upload:
- Medical records
- Itemized bills
- Payment dispute
- EOB
- General correspondence
- Consent forms
The digital attachment tool file size expansion is just one example of how Anthem is using digital technology to improve the healthcare experience, with a goal to save you valuable time.
Access the attachment tool through availity.com. From the Claims & Payments header, select Attachments – New. For more information about how to setup electronic attachments, use the Getting Started Guide: Select Help & Training > Find Help and then the Attachments topic in Contents. Once logged on you can also access the Getting Started Guide using this link.
For information about setting up for Program Integrity attachments, once logged on to Availity, use this link. You can also access Program Integrity attachment information from the Custom Learning Center: Payer Spaces > Custom Learning Center > Electronic Medical Records.
Effective August 1, 2021, the following Anthem Blue Cross and Blue Shield (Anthem) clinical guideline will be implemented and will require prior authorization for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
CG-TRANS-02 Kidney Transplantation
This guideline addresses kidney transplantation, involving the removal of the kidney from a deceased or living donor with the implantation into a single recipient.
This requirement applies to Commercial members covered by Anthem Blue products, consumer-driven health plans (CDHP), and Traditional products in 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.
Effective for dates of service on and after May 1, 2021, the following update will apply to the AIM Oncologic Imaging Clinical Appropriateness Guideline as recommended by the United States Preventive Service Taskforce Lung Cancer: Screening statement.
- Expanded low-dose CT screening for ages equal to or greater than 50 and less than or equal to 80 AND 20 or greater pack-year history of cigarette smoking.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 800-554-0580, Monday through Friday, 8:30 a.m. to 7 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.
Effective August 1, 2021, AIM Specialty Health® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the initial evaluation service codes and requested site of service for physical, occupational and speech therapy procedures for Anthem fully insured members, as further outlined below.
AIM will continue to manage physical therapy (PT), occupational therapy (OT) and speech therapy (ST) medical necessity reviews and will require pre-certification for all outpatient facility and office-based rehabilitative and habiliative services. Prior authorization will now also be required 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. AIM will use the Anthem clinical UM guideline, 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 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 from birth to 3rd birthday.
A complete list of CPT codes requiring prior authorization for the AIM Rehabilitation program is available on the AIM Rehabilitation microsite. To determine if prior authorization is needed for an Anthem member on or after August 1, 2021, providers can contact the Anthem Provider Services phone number on the back of the member’s ID card for benefit information. They will be informed whether the AIM Rehabilitation program applies. AIM will also have a file upload from the health plan of the in-scope membership and will not provide prior authorization for members who are out of scope. If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient rehabilitative or habilitative service, ICR will produce a message referring the provider to AIM.
Note: ICR cannot accept prior authorization requests for services administered by AIM.
Members included in the new program
All fully insured members currently participating in the AIM Rehabilitative program are included. Medicaid members will be included in a separate communication.
The following groups are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR, and Federal Employee Program® (FEP®).
For self-funded (ASO) groups that currently participate in the AIM Rehabilitative program, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package.
For services provided on or after August 1, 2021, ordering and servicing providers may begin contacting AIM beginning July 19, 2021 for review. Providers may submit prior authorization requests to AIM in one of several ways.
- Access AIM’s ProviderPortallSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number at 800-554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. ET.
Initiating a request on AIM’s ProviderPortalSM for PT/OT/ST and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the Order ID, the number of visits and valid time frame. The AIM Rehabilitation Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM rehabilitation training webinars
Anthem 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 register for an upcoming webinar on June 22, 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.
To more appropriately align program intention to support member care coordination and to ensure compliance with regulatory requirements surrounding the program, Anthem Blue Cross and Blue Shield (Anthem) is amending the approach for enhanced reimbursement that accompanies selection of “on-pathway” chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program.
Effective July 1, 2021, enhanced reimbursements for medical oncologists selecting on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy authorization process will be adjusted for specific regimens.
Impacted regimens include only select oral and hormonal agents for which a monthly in-office visit may not be required. For these impacted regimens, the optional enhanced reimbursement award, billable using S-codes for treatment planning and care coordination management for cancer, will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353).
This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates.
AIM/Anthem will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support.
Click here to view the list of the specific regimens that will be impacted by these changes.
Contact your Anthem network representative or your oncology provider engagement liaison for more information.
As a reminder, Anthem Blue Cross and Blue Shield (Anthem) announced the delay of a change to our facility reimbursement policy Claims Requiring Additional Documentation in the October 2020 edition of the Provider News. The change would have required facilities to submit an itemized bill with outpatient facility claims reimbursed at a percent of charge with billed charges above $20,000. We are raising the billed charges threshold to $50,000 for outpatient and will now implement with dates of service on or after August 1, 2021.
In addition, we are raising the itemized bill requirement for inpatient stay claims threshold from $40,000 to $100,000 and will now implement with dates of service on or after August 1, 2021.
As a reminder, Anthem Blue Cross and Blue Shield (Anthem) does not allow separate reimbursement for claims that have been identified as a readmission for the same, similar or closely-related diagnoses or condition to the same facility or another facility that (i) operates under the same Facility Agreement, (ii) has the same tax identification number as Facility, or (iii) is under common ownership as Facility, as further described in the existing reimbursement policy found here: Reimbursement Policies
If Anthem determines that this reimbursement policy has not been followed, Anthem may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Anthem, and Anthem policies.
In the January 2021 edition of Provider News, we shared information regarding changes to the Frequency Editing Professional Reimbursement Policy. The notice indicated that constant attendance, timed modalities for physical therapy, occupational therapy or speech therapy are limited to 4 Units or 1 hour per date of service for the same member, by the same provider, per therapy type for (97110–97124, 97129, 97130, 97140, 97533–97542, 97760–97763).
Upon further review, we have reconsidered our position and have removed this edit for dates of service on or after April 1, 2021.
In the March 2021 issue of Provider News, we advised we would no longer require prior authorization for the following drugs used to treat ocular conditions effective May 1, 2021. Please be advised that prior authorization will continue to be required for these drugs. We apologize for any inconvenience.
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Drug
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Code
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Code description
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|
*Avastin
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C9257, J9035
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intravitreal bevacizumab
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|
*Mvasi
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Q5107
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bevacizumab-awwb
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|
*Zirabev
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Q5118
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bevacizumab-bvzr
|
*Non-oncology use is managed by Anthem’s medical specialty drug review team.
Prior authorization updates
Effective for dates of service on and after August 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.
To access the Clinical Criteria information, click here.
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-0186
|
J3490, J3590, J9999
|
Margenza
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|
*ING-CC-0187
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J3490, J3590, J9999
|
Breyanzi
|
|
*ING-CC-0188
|
J3490, J3590
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Imcivree
|
|
*ING-CC-0189
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J3490, J3590, C9399
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Amondys 45
|
|
*ING-CC-0190
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J3490, J3590, C9399
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Nulibry
|
|
**ING-CC-0094
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J9304
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Pemfexy
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|
**ING-CC-0075
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J3590, J9999, C9399
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Riabni
|
* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
Prior authorization update – change in clinical criteria
Coding Update: Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.
Quantity limit updates
Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the Clinical Criteria information, click here.
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-0189
|
J3490. J3590, C9399
|
Amondys 45
|
|
*ING-CC-0190
|
J3490, J3590, C9399
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Nulibry
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* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | May 1, 2021 Medicaid news - May 2021Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross and Blue Shield (Anthem) contracted laboratories and identify the proper CPT codes to use.
Contact your Anthem representative if you need additional information or visit anthem.com/medicareprovider.
Refer patients to anthem.com/coronavirus to find convenient testing locations
If an Anthem member requests a COVID-19 test, you may refer them to anthem.com or the Sydney Health mobile app to find testing locations near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:
- Appointments or walk-ins
- Drive-through service
- Rapid test results
- Antibody testing
- Testing for children
Consider Antigen testing as an option when rapid results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), (for example, PCR). Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
Send swab tests to Anthem-contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high-value healthcare.
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