 Provider News IndianaNovember 2022 Anthem Provider News - IndianaAs a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting them to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.
We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.
Accessing claim statuses
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
Working together to streamline processes through technology is a collaborative effort. We appreciate your feedback as we continue improving to meet your expectations. The enhancements we’ve made to the Availity Essentials* Authorization application make it faster, easier, and more efficient to submit digital authorizations for Anthem Blue Cross and Blue Shield members.
View attachments for authorizations submitted — You can now view the attachments you’ve submitted to support your authorization in the Availity Essentials authorization application.
Servicing and rendering provider — We’ve enhanced the Availity Essentials Authorization Application to enable a group option when selecting the servicing and rendering provider.
View correspondence — Access status and decision letters right from the Authorization Application Dashboard. Letters can also be downloaded or printed if needed.
Enhanced provider status — Out-of-network and in-network provider statuses are now enhanced to return fewer errors associated with provider status.
Expanded search — Search rendering and serving provider by NPI and ZIP code for quicker results.
Procedure code enhancement — Add the procedure code on an outpatient authorization for more accurate submission.
Case update features — You can now update your authorization right from your Authorization Application Dashboard.
Training sessions on the Availity Essentials authorization application are still available
Whether you prefer live training webcasts, on-demand webinar recordings, or a resource guide, we have everything you need to learn more about the Availity Essentials Authorization Application and how to make the most of it. Use this link to access the training option best for you.
The next live webcast is Wednesday, November 9, 2022, at 11 a.m. ET. Register here.
When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for Anthem Blue Cross and Blue Shield claims
The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven-calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven-calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.
Submitting Anthem Blue Cross and Blue Shield claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
New learnings added to the Provider Learning Hub.
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
Change to Prior Authorization Requirements
The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on August 11, 2022.
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.
These medical policies to not apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®). To view medical policies and utilization management guidelines applicable to FEP members, please visit fepblue.org > Policies & Guidelines.
Below are the current clinical guidelines and/or medical policies we reviewed and updates that were approved.
* Denotes prior authorization required.
|
Policy/guideline
|
Information
|
Effective date
|
|
*MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy
|
· Addresses the recent U.S. FDA-approved gene therapy product, elivaldogene autotemcel (Skysona®)
|
2/1/2023
|
|
*MED.00129 Gene Therapy for Spinal Muscular Atrophy
|
· Revised MN criterion to no more than 3 copies of SMN2
|
2/1/2023
|
|
CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
|
· Added thiopurine methyltransferase (TPMT) to scope of document and Clinical Indications MN section
· Existing CPT® code 81335 will be reviewed for MN criteria
|
2/1/2023
|
|
CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
|
· Added MN statement on decisions on extending adjuvant hormone therapy beyond 5 years in individuals with 1-3 positive lymph nodes
|
2/1/2023
|
|
*DME.00044 Robotic Arm Assistive Devices
Previously titled: Wheelchair Mounted Robotic Arm
|
· Revised title
· Rescoped the Position Statement to also address robotic feeding assistive device
· No specific code for robotic assistive feeding device, E1399 NOC already listed; considered INV&NMN
|
2/1/2023
|
|
*MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
|
· Added MN criteria for essential tremor
· CPT Category III code 0398T for intracranial MRgFUS will be reviewed for MN criteria for diagnosis G25.0 (was considered INV&NMN)
|
2/1/2023
|
|
SURG.00079 Nasal Valve Repair
Previously titled: Nasal Valve Suspension
|
· Revised title
· Revised the Position Statement
· Expanded scope of document to address an absorbable nasal implant and low-dose radiofrequency intranasal tissue remodeling for the treatment of nasal airway obstruction
· Content related to the absorbable nasal implant (Latera) moved from CG-SURG-87 to this document
· Added CPT code 30468 for absorbable nasal implant (Latera), considered INV&NMN (was addressed in CG-SURG-87); no specific code for RF remodeling considered INV&NMN, CPT 30999 NOC already listed
|
2/1/2023
|
|
SURG.00119 Endobronchial Valve Devices
|
· Added a note in the Position Statement addressing individuals unable to perform a 6‑Minute Walk Distance test
· Updated hierarchy formatting in Position Statement
|
2/1/2023
|
|
*SURG.00121 Transcatheter Heart Valve Procedures
|
· Clarified TAVR MN Clinical Indications
· Added MN statement for transcatheter Mitral Edge-to-Edge Repair/transcatheter mitral valve repair using an FDA approved device when criteria met
· Added NMN statement for transcatheter mitral edge-to-edge repair/TMVr for the treatment of primary or secondary (functional) MR when the criteria above are not met
· Revised INV/NMN statement TMVr to address transcatheter mitral edge-to-edge repair for all “other” indications
· CPT codes 33418, 33419 specific to MitraClip mitral valve procedure will be reviewed for MN criteria (were INV&NMN), and added associated ICD-10-PCS code (other mitral valve codes still considered INV&NMN)
|
2/1/2023
|
|
*SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
|
· Added MN criteria for hypoglossal nerve stimulation as a treatment of OSA in individuals with Down syndrome
· Removed examples from the NMN indications
· Hypoglossal nerve stimulation codes will be reviewed for MN criteria for diagnosis codes Q90.0-Q90.9
|
2/1/2023
|
|
*CG-GENE-13 Genetic Testing for Inherited Diseases
|
· Interim update to add genes PIK3CA and CDKL5 to the table of genes in the Discussion section; added existing CPT code 81309 and genes to Tier 2 codes 81405, 81406 (MN criteria)
|
2/1/2023
|
|
*SURG.00150 Leadless Pacemaker
|
· Moving from Post Service Review to Prior Authorization
|
2/1/2023
|
Below are clinical guidelines and/or medical policies that will be moving from Post Service Review to Prior Authorization effective February 1, 2023.
|
Policy/guideline
|
Title
|
Effective date
|
|
CG-LAB-13
|
Skin Nerve Fiber Density Testing
|
2/1/2023
|
|
LAB.00027
|
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
|
2/1/2023
|
|
MED.00099
|
Navigational Bronchoscopy
|
2/1/2023
|
|
SURG.00036
|
Fetal Surgery for Prenatally Diagnosed Malformations
|
2/1/2023
|
|
SURG.00070
|
Photocoagulation of Macular Drusen
|
2/1/2023
|
|
SURG.00082
|
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
|
2/1/2023
|
|
SURG.00116
|
High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
|
2/1/2023
|
|
SURG.00120
|
Internal Rib Fixation Systems
|
2/1/2023
|
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Indiana.
Effective November 6, 2022, Anthem will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
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 Availity* at availity.com.
If you have questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Additionally, you may access and download a copy of the current and upcoming guidelines here.
Change to Prior Authorization Requirements
In the July edition of Provider News, we announced a Place of Service — Facility reimbursement policy indicating that evaluation & management (E/M) services and other professional services must be billed on a CMS-1500 claim form and are not reimbursable when billed on a UB-04 claim form (excluding E/M services rendered in an emergency room and billed with ER revenue codes).
It has come to our attention that some of the preventive counseling CPT® codes mentioned in the July article were listed incorrectly. The correct preventive counseling CPT codes are 99401–99404, 99411, and 99412, and are not reimbursable when billed in an outpatient setting of a facility effective with dates of service on or after February 1, 2023.
Please note, however, that the revenue codes 960-983 and the E/M services noted in the July edition were listed correctly in the Place of Service — Facility reimbursement policy effective with dates of service on or after October 1, 2022.
For specific policy details, visit the reimbursement policy page on our provider website.
Pathway Essentials is a new network available in Indiana as an individual marketplace/ exchange option in 2022.
Please refer to this Quick Reference Guide to help your provider organization learn about this network. For questions on your participation in this network, please reach out to your assigned Provider Experience consultant.
Change to Prior Authorization Requirements
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Fylnetra (pegfilgrastim-pbbk)
|
J3590
|
|
ING-CC-0002*
|
Rolvedon (eflapegrastim-xnst)
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Stimufend (pegfilgrastim-fpgk)
|
C9399, J3490, J3590
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Site of care updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0065
|
Advate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Adynovate (factor vii)
|
J7207
|
|
ING-CC-0065
|
Afstyla (antihemophilic factor (recombinant) single chain))
|
J7210
|
|
ING-CC-0065
|
Alphanate (antihemophilic factor viii)
|
J7186
|
|
ING-CC-0065
|
Eloctate (recombinant antihemophilic factor)
|
J7205
|
|
ING-CC-0065
|
Esperoct (factor viii recombinant, glycopegylated)
|
J7204
|
|
ING-CC-0065
|
factor viii, anti-hemophilic factor (porcine)
|
J7191
|
|
ING-CC-0065
|
Hemlibra (emicizumab-kxwh)
|
J7170
|
|
ING-CC-0065
|
Hemofil M ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Humate-P (antihemophilic factor viii)
|
J7187
|
|
ING-CC-0065
|
Jivi (factor viii, recombinant, pegylated-aucl)
|
J7208
|
|
ING-CC-0065
|
Koate DVI ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Kogenate-FS (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Kovaltry (factor viii (antihemophilic factor, recombinant))
|
J7211
|
|
ING-CC-0065
|
Novoeight (factor viii (antihemophilic factor, recombinant))
|
J7182
|
|
ING-CC-0065
|
Nuwiq (factor viii (antihemophilic factor, recombinant))
|
J7209
|
|
ING-CC-0065
|
Obizur (antihemophilic factor viii (recombinant))
|
J7188
|
|
ING-CC-0065
|
Recombinate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Vonvendi (von willebrand factor)
|
J7179
|
|
ING-CC-0065
|
Wilate (antihemophilic factor viii)
|
J7183
|
|
ING-CC-0065
|
Xyntha (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0065
|
Xyntha Solofus (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0148
|
AlphaNine SD (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Alprolix (recombinant coagulation factor ix)
|
J7201
|
|
ING-CC-0148
|
Benefix (factor ix recombinant)
|
J7195
|
|
ING-CC-0148
|
Idelvion (factor ix)
|
J7202
|
|
ING-CC-0148
|
Ixinity (factor ix)
|
J7195
|
|
ING-CC-0148
|
Mononine (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Profilnine SD (factor ix complex human)
|
J7194
|
|
ING-CC-0148
|
Rebinyn (glycopegylated)
|
J7203
|
|
ING-CC-0148
|
Rixubis (factor ix recombinant)
|
J7200
|
|
ING-CC-0149
|
Coagadex (factor x)
|
J7175
|
|
ING-CC-0149
|
Corifact (factor xiii concentrate (human))
|
J7180
|
|
ING-CC-0149
|
Feiba (anti-inhibitor coagulant complex)
|
J7198
|
|
ING-CC-0149
|
Fibryga (human fibrinogen)
|
J7177
|
|
ING-CC-0149
|
NovoSeven RT (factor viia recombinant)
|
J7189
|
|
ING-CC-0149
|
RiaSTAP (fibrinogen concentrate)
|
J7178
|
|
ING-CC-0149
|
Sevenfact (factor vlla recombinant)
|
J7212
|
|
ING-CC-0149
|
Tretten (coagulation factor xiii a-subunit (recombinant))
|
J7181
|
Step therapy updates
Effective for dates of service on and after February 1, 2023, 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.
Clinical criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Fylnetra
|
J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Rolvedon
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Stimufend
|
C9399, J3490, J3590
|
|
ING-CC-0002
|
Preferred
|
Neulasta
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Neulasta OnPro
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
ING-CC-0002
|
Non-preferred
|
Nyvepria
|
Q5122
|
|
ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
This is a courtesy notice that there is a non-material change in the clinical criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).
Quantity limit updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0017
|
Xiaflex (collagenase clostridium histolyticum)
|
J0775
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0182
|
Feraheme (ferumoxytol)
|
Q0138
|
|
ING-CC-0182
|
Ferrlecit (ferric gluconate)
|
J2916
|
|
ING-CC-0182
|
Infed (iron dextran)
|
J1750
|
|
ING-CC-0182
|
Injectafer (ferric injection)
|
J1439
|
|
ING-CC-0182
|
Monoferric (ferric derisomaltose)
|
J1437
|
|
ING-CC-0182
|
Venofer (iron sucrose)
|
J1756
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | November 1, 2022 Keep up with Medicaid News - November 2022State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | November 1, 2022 HEDIS 2022: Summary of Changes From NCQAThe National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS ® measures for the measurement year 2022. Below is a summary of some of the key changes.
Diabetes measures
NCQA has separated the Comprehensive Diabetes Care indicators into stand-alone measures:
- Hemoglobin A1c Control for Patients with Diabetes (Two rates reported: HbA1c Control (<8%) and Poor Control HbA1c) (>9%) (HBD)
- Eye Exam for Patients with Diabetes (EED)
- Blood Pressure Control for Patients with Diabetes (BPD)
The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move toward more outcome-based measures.
Race/ethnicity stratification
An important step to addressing healthcare disparities is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:
- Colorectal Cancer Screening (COL)
- Controlling High Blood Pressure (CBP)
- Hemoglobin A1c Control for Patients with Diabetes (HBD)
- Prenatal and Postpartum Care (PPC)
- Child and Adolescent Well Care Visits (WCV)
NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help identify and reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to advancing health equity in data and quality measurements.
Measure changes
Colorectal Cancer Screening (COL): Measures the percentage of members 45 to 75 years of age who had appropriate screening for ectal cancer. The Medicaid product was added to the administrative data collection method for this measure and the age range was changed to 45 to 75 years of age. Any of the following meet criteria:
- Fecal occult blood test during the measurement year
- Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year
- Colonoscopy during the measurement year or the nine years prior to the measurement year
- CT colonography during the measurement year or the four years prior to the measurement year
- Stool DNA (sDNA) with the FIT test during the measurement year or the two years prior to the measurement year
This measure can also be reported as an Electronic Clinical Data Reporting System measure: Colorectal Cancer Screening (COL-E).
Antibiotic Utilization for Respiratory Conditions (AXR): A newly added metric that measures the percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event. This measure was added because antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse.
Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the broader Antibiotic Utilization measure has been retired.
Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line of business, and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.
For a complete summary of 2022 HEDIS changes, visit: https://www.ncqa.org/hedis/measures/.
State & Federal | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | November 1, 2022 Alcohol use disorders often coexist with psychiatric disordersAlcohol use disorders (AUD) often coexist with, contribute to, or result from many different psychiatric disorders. 1 Because AUD can mimic and complicate many mental health disorders, AUD leads to challenges in diagnoses for psychiatric complaints.
Heavy alcohol use directly affects brain function and may manifest as a broad range of psychiatric symptoms. Common mental health symptoms of AUD include depression and anxiety.
In addition, patients diagnosed with mental health disorders are more likely to use a high amount of mental health services, have difficulties decreasing alcohol consumption, and struggle with suicidal ideation or attempts.
Common co-occurring mental health conditions include depressive disorders, anxiety, schizophrenia, and bipolar disorders.
Depressive disorders:2
AUD and depressive disorders are among the most prevalent co-occuring disorders. Depressive disorders are the most common comorbid mental health conditions with AUD. People with AUD are 2 to 3 times more likely to have depression. People with alcohol dependence are more likely to have a depressive disorder than those with alcohol abuse.
Co-occurring AUD and depressive disorders disproportionately affect women, as these disorders are two times more likely to occur in women than in men. Racial and ethnic minorities also encounter systemic disadvantages. For instance, Black and Latino people are significantly less likely to receive integrated mental health and substance use treatment than other races and ethnicities.
Research suggests that AUD is equally as likely to precede depression as well as for depression to precede AUD. In addition, having one increases the risk of having the other. Though the etiology of these disorders is not fully known, studies have identified some evidence of genetic predisposition or dysfunction in reward and stress systems of the brain.
Anxiety:3
Up to half of patients receiving treatment for AUD meet the criteria for one or more anxiety disorders. Data shows that patients with anxiety disorders have poorer outcomes in treatment for alcohol use. Conventional treatment for anxiety (antidepressants and behavioral therapy) do not appear to reduce AUD. This suggests that co-occurring anxiety and AUD benefits from being treated separately but simultaneously.
In addition, patients with an anxiety disorder or AUD experience an increased risk in developing the other disorder. Trauma, chronic stress, and other inheritable traits are associated with the dysfunction in stress‑response systems present in AUD and anxiety disorders.
Schizophrenia:4
The prevalence of schizophrenia is about 1% of the population; however, patients with schizophrenia are at a three times greater risk for AUD. Between 25% to 36% of patients with schizophrenia meet the criteria for AUD. Schizophrenia has a strong genetic risk factor, and a large genome-wide study revealed a significant genetic correlation between schizophrenia and AUD.
There are several theories as to why AUD is so highly prevalent in patients with schizophrenia:
- A combination of neurobiological vulnerability (genetic risk) and environmental vulnerability (poverty, homelessness, trauma, etc.)
- The concept of self-medication, suggesting people with schizophrenia turn to alcohol for relief from their psychiatric symptoms
- Similar to depressive disorders, the hypothesis that both schizophrenia and AUD are related to a dysregulation of the reward system in the brain
Bipolar disorder:5
Bipolar disorder is the most likely psychiatric disorder to have a co‑occurring condition with a substance use disorder (SUD). Estimates for a lifetime co‑occurring bipolar disorder and AUD is between 40% to 70%. These co-occurring disorders are most common in women.
Bipolar disorder occurs in between 1.5% to 5% of the population. Like schizophrenia, bipolar disorder has a shared genetic predisposition with AUD. Heavy alcohol use worsens symptoms of bipolar disorder and can trigger episodes of mania and depression. Conversely, these episodes can lead to increased alcohol consumption. Treatment for bipolar disorder often assists in treatment for co‑occurring AUD. Mood stabilizers used to treat bipolar disorder have been shown to reduce alcohol cravings in patients with bipolar disorder.
Alcohol (and other substances) are likely triggers for the onset of bipolar disorders. In one study, substance use preceded 60% of first manic episodes.6 In juvenile cases, bipolar onset early in life is correlated with AUD development as an adult.
What if I need assistance?
If you need assistance connecting your patients to mental health or AUD treatment, contact Anthem Blue Cross and Blue Shield Provider Services at:
- Hoosier Healthwise: 866-408-6132
- Healthy Indiana Plan: 844-533-1995
- Hoosier Care Connect: 844-284-1798
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare Part B drugs
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C9399, J3490, J3590, J9999
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Opdualag (nivolumab and relatlimab-rmbw)
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C9096
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Releuko (filgrastim-ayow)
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A9699
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Pluvicto (lutetium lu 177 vipivotide tetraxetan)
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Find Care, the doctor finder and transparency tool in the Anthem Blue Cross and Blue Shield (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website at www.anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetic order, and provider name.
Beginning January 1, 2023, or later, an additional sorting option will be available for members to search by provider performance called Personalized Match. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Provider pairings with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetic order, and provider name.
- You may review a copy of the Personalized Match methodology which has been posted on Availity* – our secure web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at availity.com.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to availity.com.
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.
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