New prior authorization requireents for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.

 

Administrative

• National Accounts 2020 Pre-certification list*

 

Reimbursement Policies

• Reimbursement Policy update: Place of Service-Professional*

 

Federal Employees Health Benefits (FEHB)

• Federal Employee Program_® Specialty Pharmacy Clinical Site-of-Care prior authorization review*
• Pre-certification information for the Federal Employee Program*

 

Other Important Updates

• Medicare and Medicaid News

As we have communicated in recent newsletters, the Indiana legislature passed House Bill 1143 which, among other things, requires health care providers to submit, and health plans to accept, requests for most prior authorization requests through a secure electronic transmission beginning for requests sent on and after January 1, 2020.

 

Don’t forget…

We encourage you to register to start using the electronic portals for your prior authorization requests now. Starting early will give you time to learn to use the portals and become comfortable with them.

 

Anthem has multiple secure electronic transmission portals available for providers to submit prior authorization requests depending on the type of health service being provided.

 

• Availity. Prior authorizations for medical and behavioral health services are submitted using the Availity portal. For more information about Availity, please visit our website at https://www.anthem.com/provider/availity/. Here you can learn about all of the services offered through the Availity portal, register to use Availity, and find out how to access training on Availity.

 

• AIM ProviderPortalSM. For services administered by AIM Specialty Health®, providers may submit electronic prior authorization requests to AIM using the AIM ProviderPortalSM directly at https://providerportal.com/.

 

To learn more about this law, please visit the Indiana Legislature website and view the Indiana House Bill 1143 and the final statute Health Care Services Prior Authorization (IC 27-1-37.5-10). 

 

For more information, please view our Frequently Asked Questions (FAQ) on anthem.com. If you have additional questions, please contact Provider Services.

 

HealthSync is the next step in Anthem’s investment in value-based care. Building on the positive results we have seen as we shift the focus from volume to value, this network of high-performing practices provides synchronized end-to-end coordinated care with a focus on total population management for a better patient experience and a lower cost. This network has been offered in Indiana on a limited basis since 2018. Several customers are offering a HealthSync product for 2020, which means you may see new HealthSync members in your practices. Watch for upcoming webinars to help your teams prepare to welcome the new HealthSync members.

Exciting new changes are on the horizon for the public provider site at anthem.com. These next wave of updates include:

• A new Contact Us page that gives providers easy access to important contact information
• A redesigned Medicare Advantage page with an improved, effortless user experience
• A new Enhanced Personal Health Care (EPHC) page that provides a more prominent and easier access to information that communicates Anthem’s role in transforming health care. (EPHC is a program designed to advance and support a patient-centered approach to care delivery.)

 

Below is a preview of the new Contact Us and Medicare Advantage page:

Matrix Mobile Bus

 

As we continue our efforts to help ensure our members enrolled in Affordable Care Act (ACA) compliant plans have their chronic conditions assessed and documented each year, Anthem Blue Cross and Blue Shield (Anthem) is engaging Matrix to help encourage members – on our behalf – to schedule a mobile health clinic assessment.  A vendor, Matrix operates the largest fleet of mobile medical centers nationwide and has conducted more than 1,000,000 patient assessments since 1998 – providing convenient access to comprehensive health assessments.

 

The mobile clinic provides members with additional options to help them close any gaps in care that they may have.  In late July, Matrix began reaching out to members on our behalf by letter and phone. Our outreach efforts will continue until the end of this year.

 

Matrix works with hospitals and health plans like Anthem to deliver preventive health testing to the communities Matrix serves. Each mobile clinic has a reception area and private screening rooms. Matrix also helps members with scheduling follow-up appointments with their PCPs at the end of the assessments and forwards the PCPs a copy of any results from the health assessment.

 

Matrix In-Home Assessments

 

Matrix will perform in-home assessments where possible. The in-home assessments offer a board-certified nurse practitioner (NP) to come to a member’s home to provide a general exam, suggestions for important screenings or other tests, a full review of the medicines they take, answers to health-related questions and a personal health summary detailing their health information. A copy of the assessment will be sent to members’ PCPs to ensure continuity of care.

 

The overall goals of the mobile clinic program and the in-home program are to provide convenient, comprehensive appointments that are designed to complement the care provided by our network of physicians. These mobile clinic or in-home visits do not replace any active treatment plans members currently have with their physicians and are not considered wellness visits or a substitute for members’ annual physical examinations.

 

We’re including information about the program in this edition of Provider News should patients contact you about the program. Please refer members directly to Matrix if they have questions or need more information:

 

Mobile Bus: 888-822-3247

In-Home: 855-403-0967

The National Accounts 2020 Pre-certification list has been published.

 

Please note: Providers should continue to verify member eligibility and benefits prior to rendering services.

 

* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.

We announced in July that the AIM Rehabilitative Program for Anthem’s Commercial membership was delayed. The AIM Rehabilitative Program for prior authorization for physical, speech and occupational therapy services is scheduled to relaunch on November 1, 2019. Prior authorization requests for dates of service on or after November 1 may be submitted beginning October 21 via the AIM ProviderPortal_SM.

 

Coverage for physical, speech and occupational therapy services with dates of service July 1, 2019 through October 31, 2019 will not require prior authorization; processes have been created to allow providers to continue to provide treatment and to allow claims to adjudicate for those dates of service without authorization.  Claims that were denied for no authorization in error for dates of service after July 1, 2019 are being reprocessed. The OrthoNet program is no longer active in applicable markets.

 

We invite you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the capabilities of the AIM ProviderPortal_SM. Visit the AIM Rehabilitation microsite to register for an upcoming training session.

The upgrade to the 23rd edition of the MCG Care Guidelines for Anthem Blue Cross and Blue Shield (Anthem) has changed from May 24, 2019 to November 4, 2019. In addition, Anthem has customized some of the MCG Criteria.

 

Customizations to the 23rd edition of the MCG Care Guidelines

 

Effective November 4, 2019, the following customizations will be implemented:

• Left Atrial Appendage Closure, Percutaneous (W0157) — customized to refer to SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
• Spine, Scoliosis, Posterior Instrumentation, Pediatric (W0156) — customized to refer to Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines

 

Effective November 4, 2019, customizations will be implemented for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria, guidance and/or examples for the following:

• Clinical indications for admission:
  • Aggressive hydration needs that cannot be managed in an infusion center
  • Prolonged marrow suppression
• Regimens that cannot be managed outpatient

 

Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition (Publish date November 1, 2019).

 

For questions, contact Provider Services:

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798

 

This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

 

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem for Hoosier Healthwise, Healthy Indiana Plan (HIP), Hoosier Care Connect and Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following codes:

• 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
• 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
• 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
• 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
• 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
• 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
• 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
• 33271 — Insertion of subcutaneous implantable defibrillator electrode
• 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
• 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (for example, Maple syrup urine disease) gene analysis, common variants (for example, R183P, G278S, E422X)
• 81219 — CALR (calreticulin) (for example, myeloproliferative disorders), gene analysis, common variants in exon 9 
• 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (for example, Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (for example, R83C, Q347X)
• 81302 — MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; full sequence analysis
• 81303 — MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; known familial variant
• 81304 —  MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; duplication/deletion variants 
• 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81400 — Molecular pathology procedure, Level 1 (for example, identification of single germline variant for example, SNP by techniques such as restriction enzyme digestion or melt curve analysis) ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (for example, medium chain acyl dehydrogenase deficiency)
• 81401 — Molecular pathology procedure, Level 2 (for example, 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis), or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (for example, acquired imatinib resistance)
• 81402 — Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81402 — Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81407 — Molecular pathology procedure, Level 8 (for example, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (for example, generalized epilepsy with febrile seizures), full gene sequence
• 81408 — Molecular pathology procedure, Level 9 (for example, analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (for example, Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (for example, neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (for example, malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (for example, von Willebrand disease types 1 and 3), full gene sequence
• 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
• C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
• C9043 — Injection, levoleucovorin, 1 mg
• C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
• D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
• D9920 — or management, by report
• J9999 — Not otherwise classified, antineoplastic drugs
• S3850 — Genetic testing for sickle cell anemia

 

To request PA, you may use one of the following methods:

• Web: Availity.com
• Fax:
• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798
• Phone: Call applicable Provider Services phone number (see below)

 

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com. Contracted and non-contracted providers who are unable to access Availity may call our Provider Services (see numbers below) for assistance with PA requirements.

 

Provider Services:

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798
• Medicare Advantage: Call the number on the back of members’ ID cards

 

Click here for additional information about the Pharmacy benefit manager change to IngenioRx

Anthem Blue Cross and Blue Shield (Anthem) offers pregnant women several services and benefits through the New Baby, New LifeSM program. Anthem provides education, support, resources and incentives to members throughout the prenatal and postpartum period. Our goal is to ensure all pregnant members are identified early in their pregnancies so that they can take full advantage of these services.

 

We are working with Availity, the vendor supporting the Benefit Look-Up Tool you may currently use in your OB office, to get information about newly identified pregnant women. This new process, including the HEDIS® Maternity Attestation form, helps connect members to additional benefits as soon as possible using a few simple steps.

 

How it works

 

When an Anthem member of childbearing age visits the OB office, the office associate is prompted to ask the question “Is the member pregnant?” during the eligibility and benefits inquiry process. If the response is yes, the system asks about the due date, and a HEDIS Maternity Attestation form is generated for the OB office to complete. On this electronic form, providers are asked to provide other relevant information including the date of the first prenatal care visit, delivery date and postpartum visit date.

 

This new, user-friendly workflow generates timely information that aids members, providers and Anthem in improving birth outcomes with early intervention.

 

We are working hard to support providers throughout Indiana in receiving necessary training for this new workflow. If you have specific questions regarding the new Availity maternity attestation process, please feel free to reach out to Provider Services:

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798

 

Provider FAQ — Availity Portal Pregnancy Notification and HEDIS Maternity Attestation

 

1. What is the purpose of this new process?

As you know, Anthem Blue Cross and Blue Shield (Anthem) offers pregnant women several services and benefits through the New Baby, New LifeSM program. Our goal is to ensure all pregnant women are identified early in their pregnancy so they can take full advantage of the education, support, resources and incentives Anthem provides throughout the prenatal and postpartum period. This new, user-friendly workflow generates timely information that aids members, providers and Anthem in improving birth outcomes with early intervention.

 

2. When will the new pregnancy-related questions display?

The office will choose one of four maternity service types: maternity, obstetrical, gynecological and/or obstetrical/gynecological. When an OB/GYN office conducts an eligibility and benefits inquiry for an Anthem member 15 to 44 years of age in the Availity Portal, the system displays pregnancy-related questions. If the office confirms the patient is pregnant, a HEDIS® Maternity Attestation form is generated. If the patient is not pregnant, the desired eligibility and benefits information displays, and no further action is required.

 

3. How does Anthem use the information provided on the HEDIS Maternity Attestation form?

The HEDIS Maternity Attestation form helps Anthem identify pregnant women so that maternity programs can be offered to them. As part of the process, all identified pregnant women receive an OB high-risk screening as well as appropriate prenatal, postpartum and well-child health education. Therefore, it is important that you enter pregnancy data correctly into the Availity Portal.

 

4. What information is required on the maternity screening in the Availity Portal?

Only the following questions are required: “Is the patient pregnant?” and “What is the estimated due date?” If the estimated due date is not yet known, it can be skipped; however, it will appear the next time a provider uses the eligibility and benefits lookup. The HEDIS Maternity Attestation form is optional but highly desired for completion as it helps Anthem better coordinate pregnancy support for members. For example, if Anthem sees a member has not yet had important prenatal and postpartum visits, we can help the member schedule these visits. It also notifies Anthem if a pregnancy has ended prematurely so that Anthem can turn off pregnancy health education messaging.

 

5. How should the office reply when a patient presents as a transfer from another OB provider?

You should answer the pertinent pregnancy questions and complete the HEDIS Maternity Attestation form as usual. Even though the first prenatal visit question typically relates to prenatal care in the first trimester or within 42 days of plan enrollment, you can simply enter the date you first provided prenatal care for the patient.

 

6. If a patient transfers out of our practice during her prenatal course, how should the office complete the HEDIS Maternity Attestation form?

It is OK to leave the HEDIS Attestation for Maternity in a pending status as it provides Anthem with pertinent prenatal care information up to the point the patient transfers out of the practice. The form remains in place until it is automatically retired 19 months later.

 

7. If we have confirmed the patient is pregnant but suffers an early miscarriage or chooses to terminate their pregnancy, how should the office communicate this important information?

In this situation, you should select the option on the HEDIS Maternity Attestation form that states “this pregnancy ended or the baby delivered prior to 20 weeks.” This action allows the office to close out and submit the HEDIS Maternity Attestation form for this pregnancy. This will also notify Anthem that any previously initiated maternity programs should be stopped.

 

8. Do I have to answer all the questions on the HEDIS Maternity Attestation form all at once?

No, the workflow is designed so you may enter and save information as it becomes available during the pregnancy. After entering the delivery and postpartum visit dates, you are given the option to complete and submit the attestation. Until then, you may save the information you enter and continue with other tasks.

 

9. Is there an easy way for me to obtain a list of all patients for whom I need to enter prenatal or postpartum visit dates?

You will receive two notifications to complete the HEDIS Maternity Attestation form.

In order to prompt you to complete the form and enter the first prenatal visit date, the first notification is posted at the time the form is created. In order to alert you to schedule the postpartum visit (if not already done) and to enter the postpartum visit date, the second notification is posted 14 days prior to the estimated due date. You may access the work queue at any time by going to Payer Spaces. Next, select the payer title from the list. Then, select HEDIS Attestation for Maternity.

 

10. How can I get additional help, support or training?

Availity offers integrated help and on-demand training demonstrations (select Help or Find Help and search using the keyword maternity). You can launch a training demo from associated help topics as well as the HEDIS Maternity work queue. If you have technical difficulties related to the HEDIS Maternity Attestation workflow, contact Availity at 1-800-282-4548.

 

If you have specific member concerns, please contact Provider Services:

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798

 

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

 

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem Blue Cross and Blue Shield for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following codes:

• 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
• 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
• 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
• 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
• 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
• 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
• 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
• 33271 — Insertion of subcutaneous implantable defibrillator electrode
• 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
• 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X)
• 81219 — CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9
• 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)
• 81302 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis
• 81303 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant
• 81304 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants 
• 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81400 — Molecular pathology procedure, Level 1 (e.g., identification of single germline variant e.g., SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (e.g., medium chain acyl dehydrogenase deficiency)
• 81401 — Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (e.g., acquired imatinib resistance)
• 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81407 — Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (e.g., generalized epilepsy with febrile seizures), full gene sequence
• 81408 — Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (e.g., Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (e.g., neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (e.g., malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (e.g., von Willebrand disease types 1 and 3), full gene sequence
• 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
• C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
• C9043 — Injection, levoleucovorin, 1 mg
• C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
• D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
• D9920 — or management, by report
• J9999 — Not otherwise classified, antineoplastic drugs
• S3850 — Genetic testing for sickle cell anemia

 

To request PA, you may use one of the following methods:

• Web: Availity.com
• Phone: Call the Provider Services number on the back of the member’s ID card for PA requirements.

 

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com. Contracted and non-contracted providers who are unable to access Availity may call the Provider Services number on the back of the member’s ID card for PA requirements.

 

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On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

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On January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by Anthem will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests, call 1-833-293-0661.

 

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The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment guidelines. Information for each training is outlined below. The Medicare Risk Adjustment Regulatory Compliance team developed the following two provider trainings. This update outlines the training series:

 

Medicare risk adjustment and documentation guidance (general)

 

When: Offered the first Wednesday of each month from December 5, 2018, to November 6, 2019 from 1 to 2 p.m. Eastern time

 

Learning objective: This training will provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.

 

Credit: This activity has been reviewed and is acceptable for up to one prescribed credit by the American Academy of Family Physicians.

 

If you are interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

https://antheminc.adobeconnect.com/admin/show-event-catalog?folder-id=38826374.

 

Medicare risk adjustment, documentation and coding guidance (condition specific)

 

When: Offered on the fourth Wednesday of every other month from January 23, 2019 to November 27, 2019 from 12 noon to 1 p.m. Eastern time

 

Learning objective: This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

 

Credit: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians.

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

1. Red flag HCCs, part one — Register for recording of live session.

Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration.

https://antheminc.cosocloud.com/e4i5k4h7cf3j/event/registration.html

 

2. Red Flag HCCs, part two — Register for recording of live session.

Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration.

https://antheminc.cosocloud.com/enfndbyedd5g/event/event_info.html

 

3. Opioids and more: substance abuse and dependence — Recording will play upon registration.  4. Acute, chronic and status conditions — Recording will play upon registration.

https://antheminc.cosocloud.com/eeq7am1fht49/event/registration.html

5. Behavioral health — November 27, 2019

 

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The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit the provider website at www.anthem.com/medicareprovider.

 

Notes/updates

 

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
• LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
• LAB.00033 — clarified investigational and not medically necessary statement to include 4K score and AR-V7
• OR-PR.00003:
  • Clarified medically necessary position statement criteria 2 through 4
  • Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered investigational and not medically necessary for all indications
• SURG.00011:
  • Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
  • Added new products to investigational and not medically necessary statement
• SURG.00045:
  • Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement
  • Revised title
• SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications

 

The following AIM Specialty Health® updates were approved on June 6, 2019:

• Advanced imaging:
  • Imaging of the heart
  • Oncologic imaging
  • Vascular imaging
  • Proton beam therapy
  • Rehabilitative therapies — physical therapy, occupational therapy and speech therapy (new)

 

Medical Policies

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

 

Publish date	Medical Policy	Medical Policy title	New or revised
June 13, 2019	MED.00129	Gene Therapy for Spinal Muscular Atrophy	New
June 13, 2019	GENE.00029	Genetic Testing for Breast and/or Ovarian Cancer Syndrome	Revised
June 13, 2019	* SURG.00011	Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
June 13, 2019	SURG.00023	Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures	Revised
June 13, 2019	SURG.00028	Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions	Revised
June 27, 2019	GENE.00025	Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors	Revised
June 27, 2019	DRUG.00046	Ipilimumab (Yervoy®)	Revised
June 27, 2019	DRUG.00053	Carfilzomib (Kyprolis®)	Revised
June 27, 2019	DRUG.00062	Obinutuzumab (Gazyva®)	Revised
June 27, 2019	DRUG.00067	Ramucirumab (Cyramza®)	Revised
June 27, 2019	DRUG.00071	Pembrolizumab (Keytruda®)	Revised
June 27, 2019	DRUG.00075	Nivolumab (Opdivo®)	Revised
June 27, 2019	DRUG.00107	Avelumab (Bavencio®)	Revised
June 27, 2019	GENE.00044	Analysis of PIK3CA Status in Tumor Cells	Revised
June 27, 2019	* SURG.00121	Transcatheter Heart Valve Procedures	Revised
June 27, 2019	GENE.00001	Genetic Testing for Cancer Susceptibility	Revised
June 27, 2019	GENE.00043	Genetic Testing of an Individual’s Genome for Inherited Diseases	Revised
June 27, 2019	LAB.00011	Analysis of Proteomic Patterns	Revised
June 27, 2019	LAB.00015	Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer	Revised
July 10, 2019	GENE.00051	Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer	New
July 10, 2019	SURG.00153	Cardiac Contractility Modulation Therapy	New
July 10, 2019	* DME.00037	Cooling Devices and Combined Cooling/Heating Devices	Revised
July 10, 2019	DME.00038	Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices	Revised
July 10, 2019	GENE.00011	Gene Expression Profiling for Managing Breast Cancer Treatment	Revised
July 10, 2019	* LAB.00027	Selected Blood, Serum and Cellular Allergy and Toxicity Tests	Revised
July 10, 2019	* LAB.00033	Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer	Revised
July 10, 2019	MED.00109	Corneal Collagen Cross-Linking	Revised
July 10, 2019	* OR-PR.00003	Microprocessor Controlled Lower Limb Prosthesis	Revised
July 10, 2019	SURG.00005	Partial Left Ventriculectomy	Revised
July 10, 2019	* SURG.00045	Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions	Revised
July 10, 2019	SURG.00120	Internal Rib Fixation Systems	Revised
September 4, 2019	GENE.00010	Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status	Revised

 

Clinical UM Guidelines

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the Medical Operations Committee for Medicare Advantage members on July 5, 2019.

 

Publish date	Clinical UM Guideline #	Clinical UM Guideline title	New or revised
June 27, 2019	CG-SURG-97	Cardioverter Defibrillators	New
June 27, 2019	CG-DRUG-98	Bendamustine Hydrochloride	Revised
June 27, 2019	CG-LAB-09	Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain	Revised
June 27, 2019	CG-LAB-14	Respiratory Viral Panel Testing in the Outpatient Setting	Revised
July 10, 2019	CG-SURG-100	Laser Trabeculoplasty and Laser Peripheral Iridotomy	New
July 10, 2019	CG-ADMIN-01	Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists	Revised
July 10, 2019	CG-ANC-06	Ambulance Services: Ground; Non-Emergent	Revised
July 10, 2019	CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy	Revised
July 10, 2019	CG-DME-07	Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)	Revised
July 10, 2019	CG-DME-08	Infant Home Apnea Monitors	Revised
July 10, 2019	CG-DME-39	Dynamic Low-Load Prolonged-Duration Stretch Devices	Revised
July 10, 2019	CG-DME-42	Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices	Revised
July 10, 2019	CG-DME-45	Ultrasound Bone Growth Stimulation	Revised
July 10, 2019	CG-MED-41	Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting	Revised
July 10, 2019	CG-MED-49	Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders	Revised
July 10, 2019	CG-MED-57	Cardiac Stress Testing with Electrocardiogram	Revised
July 10, 2019	CG-MED-59	Upper Gastrointestinal Endoscopy in Adults	Revised
July 10, 2019	CG-SURG-11	Surgical Treatment for Dupuytren's Contracture	Revised
July 10, 2019	CG-SURG-17	Trigger Point Injections	Revised
July 10, 2019	CG-SURG-35	Intracytoplasmic Sperm Injection (ICSI)	Revised
July 10, 2019	CG-SURG-49	Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities	Revised
July 10, 2019	CG-SURG-81	Cochlear Implants and Auditory Brainstem Implants	Revised
July 10, 2019	CG-SURG-85	Hip Resurfacing	Revised
July 10, 2019	CG-SURG-93	Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction	Revised
September 4, 2019	CG-GENE-11	Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status	New
September 4, 2019	CG-GENE-10	Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies	New
September 4, 2019	CG-SURG-101	Ablative Techniques as a Treatment for Barrett’s Esophagus	New
September 4, 2019	CG-SURG-102	Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy	New

 

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Aspire Health* for Medicare members in need of telephonic palliative care

 

The Aspire Telehealth Palliative Care program provides an additional layer of telephonic support to patients facing a serious illness. The program is focused on:

• Helping patients understand their diagnosis.
• Facilitating conversations with patients and their families around their goals of care.
• Ensuring patients receive care aligned with their goals and values.

 

The program begins with an initial 30 to 60 minute telephonic assessment by a specially trained Aspire Health social worker. The conversation in this initial call focuses on building rapport and completing a comprehensive assessment. This assessment includes understanding the patient's perception of their illness and current treatment plan. Follow-up calls occur every 2 to 4 weeks, typically lasting 15 to 45 minutes, with the exact frequency based on a patient's individual need.

 

Aspire Health's social workers are supported by a full interdisciplinary team of board-certified palliative care physicians, nurses, and chaplains who provide additional telephonic support to patients and their families as needed.

 

Patients enrolled in the telehealth program have access to 24/7 on-call support. The average patient is enrolled in the program for 6 to 8 months with some of the key goals being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advanced care planning documents and/or a transition to hospice when appropriate.

 

More information is available at www.aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 1-844-232-0500.

 

* Aspire Health is an independent company providing telephonic palliative care on behalf of Anthem Blue Cross and Blue Shield.

 

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• March 2019 Medical Policies and Clinical Utilization Management Guidelines update
  
  
• Clinical Laboratory Improvement Amendments for Anthem Blue Cross and Blue Shield
  
  
• Lowering health risks with no-cost statins
  
  
• Assisting your patients in managing the Donut Hole
  
  
• Prior authorization requirements for continuous positive airway
  
  
• Introducing a new fall risk program

 

• Ohio only: Introducing ConcertoHealth