 Provider News IndianaOctober 2023 Provider Newsletter Contents Prior Authorization | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | September 22, 2023 Prior authorization update
INBCBS-CDCRCM-038799-23-CPN38706 Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Beginning with claims processed on and after November 15, 2023, we will update our claims editing process for outpatient facility claims by applying the Medicare National Correct Coding Initiative (NCCI) Medically Unlikely Edits. NCCI edits are Centers for Medicare & Medicaid Services (CMS) developed guidelines to promote national correct coding based on industry standards for current coding practices. These edits provide an opportunity to shift certain existing back-end reviews to front-end adjudication for outpatient facility claims. While this may facilitate quicker claim adjudication, it may also cause claims to deny frequency unit limits tied to Medically Unlikely Edits (MUEs) if correct coding guidelines are not followed. For additional information, please visit CMS.gov and select the Medically Unlikely Edits page. If you have questions about this communication or need assistance with any other item, contact your Provider Relationship Management representative. MULTI-BCBS-CM-036615-23-CPN36574 The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed. Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance web page. Online update options include: - Add/change an address location.
- Name change.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
Reviewing your information helps us ensure your online provider directory information is current. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. MULTI-BCBS-CM-038049-23-SRS38044 Administrative | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | October 1, 2023 Clinical Laboratory Improvement AmendmentsClaims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners: Claim format and elements | CLIA number location options | Referring provider name and NPI number location options | Servicing laboratory physical location | CMS-1500 (formerly HCFA-1500) | Must be represented in field 23 | Submit the referring provider name and NPI number in fields 17 and 17b, respectively. | Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the servicing address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23. | HIPAA 5010 837 Professional | Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01 | Submit the referring provider name and NPI number in the 2310A loop, NM1 segment. | The physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02. |
To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and/or applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. If you have questions, please contact your Provider Relationship Management representative. INBCBS-CD-029150-23, CPN29147 Administrative | Commercial / Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | October 1, 2023 Help your patients continue their care and navigate Medicaid renewalDuring the COVID-19 public health emergency, Medicaid and Children’s Health Insurance Program (CHIP) members were able to stay enrolled in their current health coverage regardless of changes in eligibility or status. As Medicaid renewals begin again, your Medicaid and CHIP patients may have to take additional steps, which could include finding a new health plan. Patients who are receiving specialized care for medical conditions such as but not limited to pregnancy, chemotherapy, radiation therapy, or behavioral health therapy, may have additional concerns. They could be in the middle of treatment, scheduled for treatment, or on maintenance medications — and may be worried that they might lose access to their current care provider if they change health plans. The need for continuity of care in this changing landscapeWe’re committed to ensuring a smooth transition for your Medicaid and CHIP patients who are changing health plans. Our Continuity of Care/Transition of Care management team coordinates with you and your patients to ensure access to ongoing care. This includes a personalized evaluation of the member’s condition and network benefits to coordinate and minimize disruption of ongoing care: - Your patients can contact the number on the back of their member ID card and ask about our Transition of Care form. Once filled out, one of our dedicated nurse care managers will contact them to review their specialized care needs within 15 business days.
- Download our Medicaid provider manual to learn more about continuity of care. Refer to the table of contents and find Continuity of Care under the Provider Types, Access, and Availability section.
- Download our Commercial provider manual to learn more about our Continuity of Care/Transition of Care Program. Refer to the table of contents and find Continuity of Care/Transition of Care Program under the Quality Improvement Program section.
A proactive approach to prior authorizationsFor patients with CarelonRx, Inc.* as their pharmacy benefit manager and who are on maintenance medications or other medications for treatment, their existing, approved prior authorizations will automatically transfer to their new Anthem individual and family health plan, and there will be a one-time prior authorization applied for nonformulary medications. This will allow your patients to continue to fill their current medications and allow additional time to initiate the prior authorization process for any formulary differences. You and your patients can count on us for supportYour patients who are receiving specialized care may have concerns about continuing their care and staying with their current care providers. We want you to feel confident you have resources and answers to guide them. Together, we can ease your patients’ potential concerns and ensure a smooth transition for those who choose an Anthem individual and family health plan. If you would like more information, contact your Provider Relationship Management representative or call the number on the back of the patient’s ID card. * CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. INBCBS-CDCM-026683-23-CPN26000 Digital Solutions | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | October 1, 2023 Availity PDM application is now the intake channel for all demographic change requests, including roster uploadsAs we communicated in July, August, and September, the Provider Data Management (PDM) application on Availity Essentials* is now the only intake application to verify and initiate care provider demographic change requests, including submitting roster uploads, for all professional and facility care providers.** Previous intake channels are now retired as of October 1, 2023. If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. Training is available:- PDM application specific trainings:
- Learn about and attend one of our training opportunities by visiting here.
- View the Availity PDM quick start guide here.
Note: An Availity account is required to access these training options. If not registered yet, see below for registration details. - Roster Automation Standard Template and Roster Automation Rules of Engagement specific training:
- Listen to our recorded webinar here.
Choice and flexibility to select the option that works best for youRequest data updates via either of the following options: - Standard PDM experience
- Submitting a spreadsheet via a roster upload
Benefits to our care providers using Availity PDMThe Availity PDM application will ensure the following: - Consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
Want to submit a roster using Availity PDM?Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation:*** - Utilize the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement:
- A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. Find it online here.
- More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide).
- Upload your completed roster via the Availity PDM application.
Availity PDM compatibility check for roster submissionsAvaility PDM has been enhanced to incorporate a roster compatibility check. Providers can see if the roster was successfully submitted: - If there is an error to the roster, providers will see an error rejection message with detailed reason for the rejection.
- Errors will need to be corrected. Then, the roster should be re-uploaded. Status will show as successfully submitted once corrected and re-submitted.
- After successful submission of the roster, all accepted elements of the roster will be processed and only errors/rejections will fall out.
- Any elements that fall out will require manual intervention.
How to access the Availity PDM applicationLog onto Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts. 
Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, please ensure you have registered all TINs associated with your Availity account. If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY‑(282‑4548). ** Exclusions:- Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
- Any specific state mandates or requirements for provider demographic updates.
*** If any roster data updates require credentialing, your submission will be routed appropriately for further action. Note: The following requested adds, changes, or terminations will be routed to the Provider Contracting team for validation and impact to provider contracts and network adequacy: - Change tax ID
- Change organization name
- Add a network to agreement
- Change provider specialty
- Terminate entire agreement
INBCBS-CD-035700-23-CPN35500 As we communicated in July, August, and September, the Provider Data Management (PDM) application on Availity Essentials* is now the only intake application to verify and initiate care provider demographic change requests, including submitting roster uploads, for all professional and facility care providers.** Previous intake channels are now retired as of October 1, 2023. If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. Training is available:- PDM application specific trainings:
- Learn about and attend one of our training opportunities by visiting here.
- View the Availity PDM quick start guide here.
Note: An Availity account is required to access these training options. If not registered yet, see below for registration details. - Roster Automation Standard Template and Roster Automation Rules of Engagement specific training:
- Listen to our recorded webinar here.
Choice and flexibility to select the option that works best for youRequest data updates via either of the following options: - Standard PDM experience
- Submitting a spreadsheet via a roster upload
Benefits to our care providers using Availity PDMThe Availity PDM application will ensure the following: - Consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
Want to submit a roster using Availity PDM?Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation:*** - Utilize the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement:
- A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. Find it online here.
- More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide).
- Upload your completed roster via the Availity PDM application.
Availity PDM compatibility check for roster submissionsAvaility PDM has been enhanced to incorporate a roster compatibility check. Providers can see if the roster was successfully submitted: - If there is an error to the roster, providers will see an error rejection message with detailed reason for the rejection.
- Errors will need to be corrected. Then, the roster should be re-uploaded. Status will show as successfully submitted once corrected and re-submitted.
- After successful submission of the roster, all accepted elements of the roster will be processed and only errors/rejections will fall out.
- Any elements that fall out will require manual intervention.
How to access the Availity PDM applicationLog onto Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts.  Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, please ensure you have registered all TINs associated with your Availity account. If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY (282-4548). ** Exclusions: - Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
- Any specific state mandates or requirements for provider demographic updates.
*** If any roster data updates require credentialing, your submission will be routed appropriately for further action. Note: The following requested adds, changes, or terminations will be routed to the Provider Contracting team for validation and impact to provider contracts and network adequacy: - Change tax ID
- Change organization name
- Add a network to agreement
- Change provider specialty
- Terminate entire agreement
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of Anthem Blue Cross and Blue Shield. INBCBS-CRCM-035684-23-CPN35500 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. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetical order, and provider name. Beginning in the second quarter of 2024 or later, an additional sorting option will be available for our Medicare Advantage members to search by provider performance called Personalized Match Phase 1. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Providers 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, alphabetical order, and provider name: - You may review a copy of the Personalized Match Phase 1 methodology that has been posted on Availity* – our secure Web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Phase 1 Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at Availity.
- 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.
Anthem has expanded the scope of Personalized Match Phase 1 to include selected specialty providers and will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. * Availity, LLC is an independent company providing administrative support serviceson behalf of the health plan. MULTI-BCBS-CR-032115-23-CPN27574 Background:We continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. Provider performance can vary widely in relation to efficiency, quality, and member experience. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables. Beginning January 1, 2023, we added a new sorting option on the FindCare tool for members to leverage when they are searching for a primary care provider. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers are listed in order of their total score, though no individual scores appear within the tool or be visible to Medicare covered patients. The Personalized Match Phase 1 algorithm is based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options are still available on FindCare for our members. Personalized Match Phase 1 highlights:- We strive to make healthcare simpler, more affordable, and more accessible, and one of the ways to help achieve that goal is to ensure that consumers are connected with care providers who have strong track records delivering quality care.
- Beginning on November 10, 2023, we will upgrade the online FindCare tool for Medicare members with a new sorting option called Personalized Match Phase 1, to match consumers with providers who perform well in efficiency and quality metrics within a certain geographical distance.
- The new sorting option, known as Personalized Match Phase 1, will be the default for consumers who search for Medicare non-primary specialty care providers in FindCare.
- We currently offer Personalized Match to Commercial consumer members. Personalized Match seeks to match consumers with documented health conditions with provider ranked based on cost effectively managing quality care. For example, if a consumer who has been given a diagnosis of diabetes conducts a search, they will be matched with providers whose patients are more likely to cost effectively manage similar patients with diabetes (for example, consistently receive recommended A1c tests A consumer who is a 60-year-old male would receive different Personalized Match provider rank order than a consumer who is a 30-year-old female). The goal is to move to this full Personalized Match solution in Medicare in the future. Personalized Match Phase 1 only analyzes providers’ quality and efficiency performance regardless of member characteristics for generating the sort order.
- You may review a copy of the new sorting methodology which has been posted on Availity.*
- If you have general questions regarding this new sorting option, please submit an inquiry via the web on Availity.
- If you would like information about your scoring used for this sorting option or if you would like to request reconsideration of your score, you may do so by submitting an inquiry via the web on Availity.
- This change is part of a greater effort to help improve access to high quality, affordable healthcare, which is essential to our customers.
FAQWhy are we reimagining the strategy for evaluating non-primary specialty care providers? There is variability in provider performance (efficiency, quality, experience), and we want to ensure all members receive high-quality care that leads to improved patient outcomes. The strategy aligns with the future direction of our specialty provider care strategy. This phase of the Medicare FindCare improvement utilizes measures related to appropriate practice (for example, overuse and underuse measures). We utilize a vendor, Motive Medical, to generate an overall Appropriate Practice Score at the NPI level, based on all CMS Fee-for-Service members. How will I know my inquiry went through successfully once I submit? An email will be sent to the inquirer acknowledging receipt of inquiry within two business days. What is the turnaround time from when I submit my question to receiving an answer? The goal is to have all questions answered within two business days. If further clarification is needed, or if detailed research is required, that time frame will be extended. How will I receive my response? An email will be sent with the required information back to the email address provided during the initial inquiry request. How do I submit an inquiry? Inquiries can be made at Availity site. There are three dropdown options for inquiry types. These are: 1) General Program Inquires, 2) Request a Copy of Your Provider Performance Scorecard, and 3) Provider Performance Scorecard Inquiries. An open text field is available to describe the nature of the inquiry in more detail. What type of inquiries can I submit? Any questions relating to Personalized Match Phase 1 that is not answered in this FAQ or by the Methodology document. Do providers have any recourse if they feel their Provider Performance Scorecard is inaccurate? If a provider disagrees with their Provider Performance Scorecard results, the provider can submit an inquiry at Availity site detailing their reasoning. We will determine the best course of action as needed, but potential outcomes could be a provider consultation, reanalysis, and potentially a rescoring of provider performance to be reflected in Personalized Match Phase 1 and the Provider Performance Scorecard. What provider specialties are included in Personalized Match Phase 1? For 2023, selected non-primary specialty care providers are included. We plan to potentially incorporate other provider specialties in future provider performance evaluations. What measures are included in quality scoring and why were they included? The quality measures selected for Personalized Match Phase 1 include underuse and overuse measures, within the appropriate practice domain. Measures vary by specialty and are available on request. How are measures weighted? Motive Medical considers three factors in weighting the importance of each measure as it impacts the overall NPI Appropriate Practice Score (APS): - Measure volume (for example, the number of instances a provider is eligible for measurement)
- Cost differential (for example, the difference in cost between the inappropriate service chosen versus the cost of the appropriate alternative), and
- Patient harm (for example, measures weigh more heavily if they have a stronger negative impact on the patient).
What measurement year and source are used in quality scoring? Motive Medical’s Fall 2022 Refresh was used for quality scoring with varying claim periods by measure including dates from January 1, 2019, to December 31, 2021. What are the inclusion criteria for quality scoring? A non-primary specialist care provider must have at least three appropriateness measures with at least ten members in each measure (a few measures require 20 members) for the APS score to be calculated. If the provider does not meet this threshold, the APS score is not available. The APS score can be described in the following steps: - Within each specialty, calculate the mean Motive Medical APS score to be used as the national-specialty benchmark.
- For each non-primary care specialty provider, calculate an APS Observed to Expected (O/E) ratio, comparing the provider to the benchmark for the same specialty:
- Provider’s APS / national-specialty benchmark.
- The quality score is the provider’s APS O/E percentile ranking at the national-specialty level.
What factors go into your efficiency target? The factors going into our efficiency target are the episodes of the members are assigned to provider specialty who has the highest cost within the episode for Surgery and Evaluation costs. The observed cost of an episode is the sum of provider’s total allowed costs. The expected or peer benchmark cost of an episode is the average cost of treating the same condition or procedure with the same severity level for all specialists in the same line of business, specialty and geographic area multiplied by number of provider’s volume. For ETGs the measure is at the condition level (diabetes, asthma) and for PEGs it’s the procedure level (knee replacement, lumbar fusions): - Observed cost: Total provider cost
- Expected cost: Specialty average cost for same case mix * physician volume
- Efficiency index = observed / expected
How is your efficiency target set? Efficiency scores from the condition ETG and PEG procedure (observed/expected ratio scores) are blended into one final efficiency score by weighing the percentage of all the dollars that are tied to procedures vs conditions. This ensures that the efficiency scores for proceduralists (surgeons) are based more heavily on the procedure episodes. This is the final blended efficiency score for the provider: - A minimum of 20 episodes that have benchmarks are required to calculate a condition efficiency or procedure efficiency score for the provider.
- A 90% statistical confidence interval is computed around the provider’s final blended efficiency score to account for the level of statistical uncertainty around the point estimation. For example, a provider with a final blended efficiency score of 0.97 might have the following confidence interval: Upper confidence level (UCL) of 1.03, Lower Confidence level (LCL) of 0.91.
Cost ratings are then assigned to providers and provider groups using confidence intervals, as shown below. The provider group cost ratings are used for TIN Designation while individual provider cost ratings are used for the Provider composite score. 
For high-cost cases, how do you normalize which can occur across different groups? We exclude outlier episodes from the scoring, low cost and high-cost episodes are flagged by the software at Condition/Procedure, Severity, and Line of business level. Provider specialties with quality measures:- Cardiac electrophysiology
- Cardiac surgery
- Cardiology
- Colorectal surgery
- Endocrinology
- Gastroenterology
- General surgery
- Geriatric psychiatry
- Hand surgery
- Hematology
- Hematology/oncology
- Interventional cardiology
- Medical oncology
- Nephrology
| - Neurology
- Neurosurgery
- Obstetrics gynecology
- Ophthalmology
- Orthopedic surgery
- Otolaryngology
- Psychiatry
- Pulmonary disease
- Radiation oncology
- Rheumatology
- Surgical oncology
- Thoracic surgery
- Urology
- Vascular surgery
|
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CR-032328-23-CPN32306 Digital Solutions | Commercial / Medicare Advantage / Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | October 1, 2023 Improvements to Secure Messaging through Claims Status and Payer SpacesWe are committed to a future of shared success and therefore we are excited to announce improvements to Secure Messaging when checking claim status or when reaching out about a resolution to a previous inquiry. What’s new?In mid-October the process for Secure Messaging will change: - Through Claims Status:
- When you select Secure Messaging from the Claims Status application, the screens will be updated, creating a better navigation and accessibility experience.
- Through Payer Spaces:
- The process for submitting your secure message will stay the same through Payer Spaces. However, you will no longer use the Resources tab link to access your replies.
- You will send secure messages and receive your replies in one single location through Payer Spaces:
- Access Secure Messaging through the Payer Spaces under Applications tab.
As a reminder, to find your claims status fast, use the self-service Claim Status application on Availity.com.* Recent enhancements make it even easier and faster to get the information you are looking for. Access Claims Status from the Claims & Payments tab. For questions, contact your Provider Relationship Management representative or use Chat with Payer also available through Payer Spaces. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CDCRCM-035675-23-CPN35463 Fifty-three million Americans (more than one in five) are family caregivers. According to a new study, Caregiving in the U.S. 2020, caregivers face health challenges of their own. Nearly a quarter of caregivers find it hard to take care of their own health and say that caregiving has made their own health worse. Now, helpforcancercaregivers.org is here to help caregivers care for themselves. This interactive website, available 24/7, provides the information and resources that caregivers need to care for their own health and well-being. The website walks users through a brief survey and then provides a personalized Self-Care Guide to help them improve their health. Studies show that family caregivers suffer from poorer physical health than those who do not have additional caregiving responsibilities. Studies have also found that: - Caregivers show higher levels of depression.
- Caregivers suffer from high levels of stress and frustration — which can lead to burnout.
- Stressful caregiving situations may lead to harmful behaviors, such as abusing drugs or alcohol.
- Caregivers have an increased risk of heart disease.
- Caregivers have lower levels of self-care.
- Chronic diseases of caregivers are often more difficult to manage.
- Caregivers have an increased risk of sickness and premature death.
Evidence has also shown that education and intervention reduce caregiver strain, uncertainty, and helplessness and that information helps normalize the caregiver experience and enhances a sense of control. Caregivers for your patients can access Help for Cancer Caregivers at helpforcancercaregivers.org. MULTI-BCBS-CM-036949-23-CPN36922 Webinars | Commercial / Medicare Advantage / Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | September 22, 2023 You're invited: Thriving, not just surviving: Youth mental health in today's worldThis forum has moved from the original date of September 27, 2023 to October 19, 2023Register today for the youth mental health forum hosted by Anthem and Motivo* for Amerigroup providers on October 19, 2023. Thursday, October 19, 2023
3:30 to 5 p.m. Eastern time This important event will address the critical need to engage young people in leading their mental health. By deepening the discussion on youth mental health, we can do our part to foster a culture of understanding and support for youth and young adults. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve. Please join us to hear from a diverse panel of experienced professionals and young leaders as we explore the challenges experienced by today’s youth, amplify the experiences and ideas of young people, and equip attendees with practical tools and innovative approaches to create meaningful change. Each forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address, and deconstruct bias, have difficult and productive conversations, learn about valuable resources, increase inclusion, advance equity in healthcare. Please register for this event by visiting this link. * Motivo is an independent company providing a virtual forum on behalf of the health plan. INBCBS-CDCRCM-039377-23-CPN39367 As a contracted provider for Special Needs Plan (SNP) from Anthem Blue Cross and Blue Shield (Anthem), you are required to participate in an annual training on Model of Care for Anthem. This training includes a detailed overview of SNPs and program information — highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Training for SNP product for Anthem is self-paced and available at availity.com.* The training must be completed by December 31, 2023. How to access the Custom Learning Center on the Availity website:- Log in to Availity website at availity.com.
- At the top of Availity website, select Payer Spaces and select the appropriate payer.
- On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
- In the Custom Learning Center, select Required Training.
- Select Special Needs Plan and Model of Care Overview.
- Select Enroll.
- Select Start.
- Once the course is completed, select Begin Attestation and complete.
Not registered for Availity Essentials?Have your organization’s designated administrator register your organization for the Availity website: - Visit availity.com to register.
- Select Register.
- Select your organization type.
- In the Registration wizard, follow the prompts to complete the registration for your organization.
Refer to these PDF documents: https://apps.availity.com/availity/Demos/Registration/index.htm for complete registration instructions. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CR-022628-23, CPN22400, MULTI-BCBS-CR-039458-23-CPN39408 OverviewWe’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. Engagement Hub objectives:- Learn strategies to help you and your care team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
- Offer care providers a convenient way to earn CME credits at a time that works best for them.
- Each session in this series is approved for one American Academy of Family Physicians credit:
- Browse the listing of free CME webinars.
- Open the CME webinars in Google Chrome
MULTI-BCBS-CRCM-038423-23-CPN38131 Medical drug benefit Clinical Criteria updates On August 19, 2022, September 12, 2022, November 18, 2022, February 24, 2023, May 19, 2023, June 12, 2023, and July 11, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other providers in your practice and office staff. Note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Document number | Clinical Criteria title | New or revised | October 18, 2023 | *CC-0243 | Vyjuvek (beremagene geperpavec) | New | October 18, 2023 | *CC-0242 | Epkinly (epcoritamab-bysp) | New | October 18, 2023 | *CC-0241 | Elfabrio (pegunigalsidase alfa-iwxj) | New | October 18, 2023 | CC-0228 | Leqembi (lecanemab) | Revised | October 18, 2023 | *CC-0061 | Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications | Revised | October 18, 2023 | *CC-0015 | Infertility and HCG Agents | Revised | October 18, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised | October 18, 2023 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised | October 18, 2023 | *CC-0177 | Zilretta (triamcinolone acetonide extended-release) | Revised | October 18, 2023 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised | October 18, 2023 | CC-0032 | Botulinum Toxin | Revised | October 18, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised | October 18, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised | October 18, 2023 | *CC-0174 | Kesimpta (ofatumumab) | Revised | October 18, 2023 | *CC-0209 | Leqvio (inclisiran) | Revised | October 18, 2023 | *CC-0011 | Ocrevus (ocrelizumab) | Revised | October 18, 2023 | *CC-0005 | Hyaluronan Injections - Medicare Only | Revised |
MULTI-BCBS-CR-036939-23-CPN36113 Medical Policy & Clinical Guidelines | Commercial | October 1, 2023 Change to Prior Authorization Requirements Transition to Carelon Medical Benefits Management, Inc. site of care guidelinesEffective December 30, 2023, Anthem Blue Cross and Blue Shield (Anthem) will transition the Clinical Criteria for site of care reviews to the following Carelon Medical Benefits Management* (Caralon) site of care guidelines to perform medical necessity and clinical appropriateness reviews for the requested site of care for certain procedures. Program | Services | Carelon Guideline | CPT® code list links | Surgical | Routine outpatient surgical procedures across the following specialty services: gastroenterology (including upper and lower endoscopy), ophthalmology (such as cataract surgery), gynecology, dermatology, urology, pulmonary and musculoskeletal | Surgical Appropriate Use Criteria: Site of Service | https://tinyurl.com/8bruffkj | Radiology | Routine outpatient CT and MRI imaging such as head, chest, and extremity imaging. | Advanced Imaging Appropriate Use Criteria: Site of Care | https://tinyurl.com/y45hsv5h | Musculoskeletal | Select musculoskeletal and pain procedures, including shoulder and knee arthroscopies and epidural injections. | Surgical Appropriate Use Criteria: Site of Care | https://tinyurl.com/3xujthte | Rehabilitative Services | Routine outpatient speech, occupational, and physical therapy services | Outpatient Rehabilitative and Habilitative Services Appropriate Use Criteria: Site of Care | https://tinyurl.com/5dz92sp4 |
Note: These reviews do not apply to procedures performed on an emergent basis. Carelon Medical Benefits Management also manages the musculoskeletal level of care review using The Carelon Musculoskeletal Appropriate Use Criteria: Level of Care for Musculoskeletal Surgery and Procedures guideline. Members included in the programThe new review criteria apply to all Anthem members currently participating in the above mentioned Carelon Medical Benefits Management programs. To determine if prior authorization by Carelon Medical Benefits Management is required for a member, contact the Provider Services phone number on the back of the member’s ID card. The following members are excluded: Medicare Advantage (individual and group), Medicare, Medicare supplement, and the Federal Employee Program® (FEP). Prior authorization requirementsPrior authorization requirements remain the same. For services scheduled to begin on or after December 29, 2023, care providers must contact Carelon Medical Benefits Management to obtain prior authorization. Requested services received on or after December 29, 2023, will be reviewed with the new Clinical Criteria. Care providers may submit prior authorization requests to Carelon Medical Benefits Management at providerportal.com. Initiating a request and entering all the requested clinical information will provide an immediate determination 24/7. For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-038847-23 Medical Policy & Clinical Guidelines | Commercial | October 1, 2023 Change to Prior Authorization Requirements Medical Policies and Clinical Guidelines updates Anthem Blue Cross and Blue Shield (Anthem) Medical Policies and Clinical Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin. The chart below contains the current Clinical Guidelines and Medical Policies reviewed, and the updates that were approved. Policy or Guideline | Information | Effective date | DME.00032 Automated External Defibrillators for Home Use | Add to prior authorization | 1/1/2024 | LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | Add to prior authorization | 1/1/2024 | LAB.00011 Selected Protein Biomarker Algorithmic Assays | Add to prior authorization | 1/1/2024 | LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease | Add to prior authorization | 1/1/2024 | LAB.00024 Immune Cell Function Assay | Add to prior authorization | 1/1/2024 | LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests | Add to prior authorization | 1/1/2024 | LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis | Add to prior authorization | 1/1/2024 | LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus | Add to prior authorization | 1/1/2024 | LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) | Add to prior authorization | 1/1/2024 | LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline | Add to prior authorization | 1/1/2024 | LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease | Add to prior authorization | 1/1/2024 | LAB.00048 Pain Management Biomarker Analysis | Add to prior authorization | 1/1/2024 | GENE.00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis | Add to prior authorization | 1/1/2024 | MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Video microscopy, Ultrasonography) | Add to prior authorization | 1/1/2024 | GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | Add to prior authorization | 1/1/2024 | SURG.00092 Implanted Devices for Spinal Stenosis | Add to prior authorization | 1/1/2024 | LAB.00031 Advanced Lipoprotein Testing | Adding Code 0052U to prior authorization - Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses of HDL, LDL, and VLDL by vertic | 1/1/2024 | LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer | Adding Code 0228U to prior authorization - Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morni | 1/1/2024 | LAB.00015 Detection of Circulating Tumor Cell | Adding Code 0337U to prior authorization - Oncology (plasma cell disorders and myeloma), circulating plasma cell immunologic selection, identification, morphological characterization, and enumeration of plasma cells ba | 1/1/2024 | LAB.00015 Detection of Circulating Tumor Cell | Adding Code 0091U to prior authorization - Oncology (colorectal) screening, cell enumeration of circulating tumor cells, utilizing whole blood, algorithm, for the presence of adenoma or cancer, reported as a positive o | 1/1/2024 | LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer | Adding Code 0359U to prior authorization - Oncology (prostate cancer), analysis of all prostate-specific antigen (PSA) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer | 1/1/2024 |
* Denotes prior authorization required
To view Medical Policies and utilization management guidelines, visit Anthem.com and select Providers, then select your state. Under Provider Resources, select Policies, Guidelines, and Manuals. To help determine if prior authorization is needed for Anthem members, visit Anthem.com and select Providers, then select your state. Under Claims, select Prior Authorization. You can also call the phone number on the back of the member’s ID card. To view medical policies and utilization management guidelines applicable to members enrolled in the Federal Employee Program® (FEP), visit fepblue.org and select Policies and Guidelines. Medical Policy & Clinical Guidelines | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | July 7, 2023 Carelon Medical Benefits Management, Inc Spine & Joint Surgery Guideline UpdateCarelon Medical Benefits Management, Inc. Guideline Update The Carelon Medical Benefits Management, Inc.* guidelines below were developed and/or revised effective September 11, 2023. The guidelines were revised to provide clarification only related to the updated criteria. Existing precertification requirements have not changed. Please share this notice with other providers in your practice and office staff. To view a guideline, visit https://guidelines.carelonmedicalbenefitsmanagement.com/. Criteria number | Criteria title | New or revised | MSK03-0923.2 | Carelon Medical Benefits Management spine surgery clinical appropriateness guideline — criteria for lumbar disc arthroplasty | Revised | MSK02-1123.1 | Carelon Medical Benefits Management joint surgery clinical appropriateness guideline — criteria for meniscal allograft transplantation of the knee and osteochondral grafts | Revised |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. INBCBS-CD-025997-23 Prior Authorization | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | September 22, 2023 Prior authorization updateEffective January 1, 2024, the below CPT® codes will require prior authorization. All covered services are contingent upon medical necessity and benefit coverage at the time of service. The prior authorization (PA) lookup tool allows providers to search codes by the specific line of business (Hoosier Healthwise, Healthy Indiana Plan, or Hoosier Care Connect) to determine if PA is required and which guideline is utilized for the case review. To access the PA lookup tool, go to https://providers.anthem.com/in, and select Precertification Lookup Tool under the Claims drop-down. Detailed PA requirements are available to contracted providers via the provider self-service tool on Availity Essentials* at Availity.com or go to https://providers.anthem.com/in and select Log in to Availity. For assistance with questions regarding the PA requirement change, please call Provider Services at one of the phone numbers listed below: - Hoosier Healthwise — 866-408-6132
- Healthy Indiana Plan — 844-533-1995
- Hoosier Care Connect — 844-284-1798
Clinical Utilization Management Guidelines (CUMG) number | CUMG title | CPT code | MCG: Oncology Companion Diagnostic Testing - Guardant360 CDx (A-1056) LCD MolDX: Molecular Diagnostic Tests (MDT) (L36807) NCD Next Generation Sequencing (NGS) (90.2) Version 2 (N902v2) | Guardant360 CDx is a next-generation sequencing assay consisting of a panel of 55 genes that analyzes cell-free DNA from plasma to detect genetic alterations (in other words, single nucleotide variants, insertions and deletions, copy number amplifications, fusions) that may be found in cancer. | 0242U | LCD MolDX: Plasma-Based Genomic Profiling in Solid Tumors (L38168) LCD MolDX: Molecular Diagnostic Tests (MDT) (L36807) | Guardant360® from Guardant Health Inc. The test uses a next–generation sequencing (NGS) targeted sequence analysis panel to evaluate cell–free circulating DNA from a blood specimen for 83 or more genes associated with solid–organ neoplasms. | 0326U | MCG: Hemoglobin C and E - HBB Gene (A-0604) MCG: Beta Thalassemia - HBB Gene (A-0815) MCG: Sickle Cell Disease - HBB Gene (A-0864) | Analyze the entire gene sequence for the hemoglobin, subunit beta (HBB) gene. | 81364 | MCG: Myeloproliferative Neoplasms - MPL Gene (A-0843) | Variants of specific gene sequences of the MPL (MPL proto–oncogene, thrombopoietin receptor) gene, such as W515A, W515K, W515L, W515R, which may be associated with myeloproliferative neoplasms (MPN) such as essential thrombocythemia (ET) in JAK 2 V617F–negative patients. | 81338 |
New Reimbursement Policy
Genetic Tests: Once per Lifetime
(Policy G-23002, effective 01/01/2024) Beginning with dates of service on or after January 1, 2024, Anthem Blue Cross and Blue Shield (Anthem) will implement a new reimbursement policy titled Genetic Tests: Once per Lifetime. This policy identifies specific genetic tests allowed once in a member’s lifetime. During the member’s lifetime, the germline genotype will not change. However, the interpretation of the gene sequence may change due to recategorization of variants, or other factors. Repeat sequencing is not required for future interpretation of germline genotype, or re-analysis of previously sequenced data. The Related Coding section includes a Once per Lifetime Genetic Test coding list, which describes the genetic procedures that are limited to once per lifetime sequencing. Reinterpretation of the original results are not separately reimbursable. For additional information, please review the Genetic Tests: Once per Lifetime reimbursement policy at https://www.anthem.com/medicareprovider. MULTI-BCBS-CR-033765-23-CPN29184 Reimbursement Policies | Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging | October 1, 2023 Reimbursement policy update - Modifiers 25 and 57 Retraction
Modifiers 25 and 57
Policy G-06003, effective 04/27/2022) In the April 2023 edition of the Provider News, we announced the Modifiers 25 and 57 reimbursement policy will not allow reimbursement for CPT® code 99211 when appended with Modifiers 25, effective for dates of services on or after June 1, 2023. However, this notification was sent by mistake, and Anthem Blue Cross and Blue Shield will allow separate reimbursement for 99211 when appended with Modifier 25. For additional information, please review the Reimbursement Policy name and Hyperlink reimbursement policy at https://providers.anthem.com/inBlue High Performance NetworkSM (BlueHPNSM) plans offer access to providers with a record of delivering high-quality, efficient care. Since January 2021, we’ve been collaborating with select healthcare providers across the U.S. to make BlueHPN available to patients. Anthem Blue Cross and Blue Shield’s (Anthem) mission is to provide affordable, quality healthcare benefits to its members. This in-network only plan helps keep members’ healthcare costs more predictable and manageable. It's important to know that only in-network care is covered. Members in the BlueHPN cannot go to out-of-network doctors or hospitals, except in an urgent and/or emergent situation. If they see a provider for routine or non-urgent care outside the BlueHPN, they will be responsible for paying the total billed charges. Recognizing BlueHPN patientsYou and your staff can identify patients enrolled in BlueHPN plans by their member ID card. The Blue High Performance Network name will be prominently displayed on the front of the member ID card, along with the BlueHPN suitcase logo, as shown on this sample card. 
Eligibility and benefitsBlueHPN does not offer coverage for out-of-network care with the exception of urgent and/or emergent services. This means that BlueHPN patients will receive full benefits from in-network BlueHPN providers. You can check BlueHPN plan member eligibility and benefits the same way you do today for HealthSync members — Either submit a HIPAA 270 eligibility and benefit request transaction or contact Provider Services at the number on the back of the member’s ID card. Referrals to BlueHPN providersBlueHPN is a comprehensive network that includes a full range of providers, from primary care doctors and specialists to hospitals. Not all healthcare providers are included. To ensure your BlueHPN patients will have full benefits when they need to see a specialist or another healthcare provider, it’s important that you only recommend other BlueHPN healthcare providers. You can use the Find a Doctor/Find Care tool at Anthem.com to identify BlueHPN healthcare providers by searching by the member’s ID or alpha prefix. This will help ensure your patients will be receiving care from healthcare providers who are also committed to quality care and cost-efficiency. Formal physician-to-physician referrals are not required under BlueHPN plans, but out-of-network benefits are limited to urgent and/or emergent services only. That means referrals for non-emergency care to providers outside the BlueHPN network would be costly for your patients, including durable medical equipment and laboratory services. Additional network informationMore than 60 large metropolitan areas have their own high-performance networks sponsored by local Blue Cross and Blue Shield plans across the country, which gives national employers access to high quality, cost-efficient providers in these geographic areas. The Indiana BlueHPN uses the existing HealthSync network; therefore, you may see both local patients who have access to HealthSync through the Anthem plan and patients traveling from other cities where BlueHPN products are offered. Indiana-based employer-sponsored health plans with access to our Indiana High-Performance Network refer to the BlueHPN as HealthSync. If you are not sure whether your practice is part of the Indiana BlueHPN — HealthSync, ask your office manager or business office or you can also contact your Anthem Provider Relationship account manager to find out or if you have any additional questions. Pharmacy | Commercial | October 1, 2023 Change to Prior Authorization Requirements Specialty pharmacy updates — October 2023Specialty 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 Carelon Medical Benefits Management, Inc.* 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. Including the 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 updatesEffective for dates of service on and after January 1, 2024, 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) | CC-0244* | Columvi (glofitamab-gxbm) | C9399, J3490, J3590, J9999 | CC-0245 | Izervay (avacincaptad pegol) | C9399, J3490, J3590, J9999 | CC-0246 | Rystiggo (rozanolixizumab-noli) | C9399, J3490, J3590, J9999 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updatesCourtesy notice — Effective for dates of service on and after October 1, 2023, updated step therapy criteria for iron agents found in the clinical criteria document for CC-0182 will be implemented. The preferred product list is being expanded to include Infed. Please refer to the clinical criteria document for details. Access our Clinical Criteria to view the complete information for these step therapy updates. Quantity limit updatesEffective for dates of service on and after January 1, 2024, 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) | CC-0245 | Izervay (avacincaptad pegol) | C9399, J3490, J3590, J9999 | CC-0246 | Rystiggo (rozanolixizumab-noli) | C9399, J3490, J3590, J9999 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-038617-23-CPN38572 Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list The previous effective date was previously listed in error as October 1, 2023, this correct effective date is December 1, 2023. Effective for dates of service on and after December 1, 2023, 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. HCPCS or CPT® codes | Medicare Part B drugs | J9029 | Adstiladrin (nadofaragene firadenovec-vncg) | C9399, J7199 | Altuviiio (antihemophilic factor (recombinant) | C9399, J3490 | Lamzede (velmanase alfa-tycv) | J9350 | Lunsumio (mosunetuzumab-axgb) | J1440 | Rebyota (fecal microbiota, live – jslm) | J2502 | Signifor LAR (pasireotide) | C9151, C9399, J3490 | Syfovre (pegcetacoplan) | J9056 | Vivimusta (bendamustine) |
MULTI-BCBS-CR-023557-23-CPN23416 Expanded specialty pharmacy precertification list Effective for dates of service on and after January 1, 2024, 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. HCPCS or CPT® codes | Medicare Part B drugs | J3490, J3590 | Elfabrio (pegunigalsidase alfa-iwxj) | C9399, J3490, J3590, J9999 | Epkinly (epcoritamab-bysp) | J3490, J3590 | Qalsody (tofersen) | J3490, J3590 | Vyjuvek (beremagene geperpavec) | J9999 | Zynyz (retifanlimab-dlwr) |
MULTI-BCBS-CR-037831-23-CPN37401 |