Improvements in search capabilities in Availity Essentials now result in faster and more accurate results.

To help save you more time upfront while receiving more detailed eligibility and benefits information, we’ve expanded the Current Procedural Terminology^® (CPT) code search capabilities in Availity Essentials’ Eligibility and Benefit app.

These optimizations enable the use of up to eight specific CPT or HCPCS codes per transaction for faster, more accurate, and personalized search results, which include:

• Authorization requirement notifications, so you know up-front if an authorization is needed.
• Additional plan-level benefit limitations details.
• Cost-share information displayed by places of service and procedure codes.

Making these details available on the search results pages can help you save time and effort by giving you access to the right information you need when you need it. Additionally, it reduces the need to contact us, resulting in fewer calls and chats over time.

Watch the recorded training to see how you can start saving time today. Learning sessions show step-by-step how you can use the CPT code search capabilities in Availity Essentials to help increase your productivity. We're dedicated to supporting your success through digital solutions that help reduce your administrative burden and streamline your interactions with us.

If you have any questions, contact your provider relationship management representative.

We have previously communicated to you that we are digitizing the authorization case notifications regarding status and decision letters, eliminating paper notifications, with the commercial health plans. We are happy to share with you that we are now also expanding the digitization of authorization case notifications for Medicare Advantage and Medicaid plans from Anthem in your state.

Just as you have with commercial health plans, you have 24/7 access to authorization case information in one location through Availity Essentials. The digital authorization case status notifications are available under the Authorizations and Referrals* application once you have logged in to Availity Essentials and selected Patient Registration. By eliminating the redundancy of receiving both a digital and paper letter, you’ll see fewer errors associated with manual processes in handling the paper letters while reducing cost and our carbon footprint.

* Note: your Availity Essentials administrator must assign you the role of Authorization & Referral Inquiry or Request to access this application.

Care providers will be able to choose different options to receive authorization decision notifications via the Provider Preference Center under Availity Payer Spaces. Look for details on the Provider Preference Center options and ways to access authorization case status in an upcoming communication.

We are focused on reducing administrative burdens, so you can do what you do best — care for your patients.

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised during Q4 2023. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/provider/policies/clinical-guidelines/search/.

Clinical UM Guidelines

On November 9, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members on January 4, 2024. These guidelines take effect October 10, 2024.

The following Medical Policies and Clinical UM Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view medical policies and utilization management guidelines, go to anthem.com > select Providers > select your state > under Provider Resources > select Policies, Guidelines & Manuals.

To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > select your state > under Claims > select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card.

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program^® FEP), please visit fepblue.org > Policies & Guidelines.

Below are the new medical policies and/or clinical guidelines that have been approved.

* Denotes prior authorization required

Below are the current clinical guidelines and/or medical policies we reviewed, and updates were approved.

* Denotes prior authorization required

Effective October 25, 2024, our Medicaid plans will align with Indiana Health Coverage Program (IHCP) fee-for-service (FFS) for hospice services for the following programs: Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging. This includes the following covered services: home hospice, hospice in a nursing facility (includes room and board), hospice in a hospice facility, and respite hospice care. The following changes will be applied to all hospice services. All hospice care providers must send notification of services.

For dually eligible (Medicare and Medicaid) hospice members, hospice care providers should refer to eligibility requirements in Code of Federal Regulations 42 CFR 418.20, which states:

In order to be eligible to elect hospice care under Medicare, an individual must be: (a) Entitled to Part A of Medicare; and (b) Certified as being terminally ill in accordance with 418.22.

Medicaid-only (non-dual) hospice members must be eligible for the Medicaid program and be certified as terminally ill in accordance with 42 CFR 418.22. Furthermore, the medical documentation contained in the form Medicaid Hospice Physician Certification (state form 48736 [R/12-02]/OMPP 0006) and the form Medicaid Hospice Plan of Care (state form 48731 [R2/11-04]/OMPP 0011) must support a terminal diagnosis versus a chronic condition.

Continuity of care (COC) notifications

Fax the required documentation to 844-765-5157. The notification must contain:

• IHCP prior authorization (PA) form, including:
  • CPT^®/HCPCS code applicable to the hospice service (see below for codes).
  • Do not list revenue codes on the PA form.
  • In the note section of the IHCP PA form, enter COC.
• The approval letter from FFS or previous MCE containing the allowed units and dates of service:
  • COC dates of service will begin the date the member became eligible and approved for 90 days.
  • If the previously approved service ends prior to the 90th day, the end date of service will follow the approved end date.
• If services need to continue after the COC period:
  • Submit the notification 14 days before the COC period expires.
  • Include the documentation as outlined below.

Notification of dual members

Service: hospice in a nursing facility or in a hospice facility

Submit the following documentation by fax to 844-765-5157:

• IHCP PA form, including:
  • The nursing facility or hospice facility National Payer Identifier (NPI) and tax ID (enter in the note section of the PA form).
  • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5003, Q5004, Q5006, Q5007, or T2046).
  • Do not include revenue codes on the IHCP PA form.
  • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
• Hospice election form
• MD signed certification for terminal illness with less than six months of life expectancy
• Hospice authorization for dually eligible nursing facility residents’ form

Notification for non-dual members

Service: hospice in a nursing facility or in a hospice facility

Submit the following documentation by fax to 844-765-5157:

• IHCP PA form, including:
  • The nursing facility or hospice facility NPI and tax ID (enter in the note section of the PA form)
  • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5003, Q5004, Q5006, Q5007, or T2046).
  • Do not include revenue codes on the IHCP PA form.
  • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
• Hospice election form
• MD signed certification for terminal illness with less than six months of life expectancy

Notification for all members

Service: home hospice and continuous home hospice

Submit the following documentation by fax to 844-765-5157:

• IHCP PA form, including:
  • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5001, T2042, or T2043)
  • Do not include revenue codes on the IHCP PA form.
  • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
• Hospice election form
• MD signed certification for terminal illness with less than six months of life expectancy

Notification for all members

Service: respite hospice

Submit the following documentation by fax to 844-765-5157:

• IHCP PA form, including:
  • Enter a CPT/HCPCS code (one of the following codes must be listed: H0045, T1005, or T2044).
  • If the respite service is for a nursing facility, hospice facility or a hospital, list the NPI and tax ID (enter in the note section of the PA form).
  • Do not include revenue codes on the IHCP PA form.
  • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
• Hospice election form..
• MD signed certification for terminal illness with less than six months of life expectancy

Note: Inpatient respite hospice is allowable only for members who are otherwise residing in a private home and are admitted to the indicated facility for a respite stay only.

Notification for all members

Service: general inpatient hospice related to the terminal illness

Submit the following documentation by fax to 844-765-5157:

• IHCP PA form, including:
  • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5005 or T2045).
  • If the respite service is for a nursing facility, hospice facility or a hospital, list the NPI and tax ID (enter in the note section of the PA form).
  • Do not include revenue codes on the IHCP PA form.
  • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
• Hospice election form.
• MD signed certification for terminal illness with less than six months of life expectancy.

If the hospice provider has an arrangement with a facility to provide short-term inpatient care, the arrangement must be described in a written agreement. The written arrangement must meet the requirements of 42 CFR 418.108(c). Arranged services must be supported by written agreements as described in 42 CFR 418.100(e).

These services are notification only, and no medical necessity review is conducted. With that, if any of the above elements are missing, Anthem will attempt to call the requesting care provider and/or fax the PA form back to the requesting care provider to submit the missing elements.

Benefit periods

Notification of hospice services must be submitted for each of the benefit period 90-90-60 (see table below), then the open-ended services will begin with notification of the fourth benefit period. The face-to-face encounter must be submitted with the (fourth benefit period — open-ended benefit period). The open-ended benefit period will be open for two years. Please submit approximately 14 days before the authorization expires to fax number 844-765-5157.

Open-ended hospice benefit period

405 IAC 5-34-5 requires that a hospice physician or a hospice nurse practitioner must have a face-to-face encounter with a member receiving hospice care to determine continued eligibility for hospice care for the member’s third benefit period and every benefit period thereafter. The face-to-face encounter must occur not more than 30 calendar days before recertification of the third benefit period and of every subsequent benefit period.

For hospice members in Healthy Indiana Plan, Hoosier Care Connect, and PathWays who require inpatient care, hospice care provider responsibilities depend on whether the stay is related to the terminal illness.

For inpatient stays related to the terminal illness, at the general inpatient hospice level of service or the inpatient respite hospice level of service, the hospice care provider is responsible for the following:

• Obtaining contracts with all IHCP care providers for arranged services:
  • Reimbursing the facility according to the contract between the hospice care provider and the facility where the member receives care (Note: The contract between the hospice provider and the facility covers all costs related to the terminal illness.)
  • Submitting claims directly to the MCE for reimbursement. (Note: The hospice care provider will be paid at the rate appropriate to the level of service provided to the hospice member; general inpatient hospice level of service will be reimbursed at the general inpatient rate; and inpatient respite hospice level of service will be reimbursed at the respite rate.)

For members receiving inpatient care unrelated to the terminal illness, the facility is responsible for: obtaining PA, as required, from the MCE; submitting claims directly to the MCE for reimbursement; all the member’s care and treatment while the member remains at the facility.

For assistance with questions regarding the PA requirement change, please call Provider Services for the plan listed below.

Effective October 1, 2024, the below CPT^® codes will require prior authorization (PA). All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The PA lookup tool allows providers to search codes by the specific line of business (Medicaid/SCHIP/Family Care, 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 providers.anthem.com/in, and select Precertification Lookup Tool under the Claims drop-down.

Contracted providers can also access the provider look up tool via Availity Essentials at Availity.com by selecting Payer Spaces and then selecting the Pre-cert Lookup tool tile.

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
• Indiana PathWays for Aging — 833-412-4405

Effective October 1, 2024, the below CPT^® codes will require prior authorization (PA). All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The PA lookup tool allows providers to search codes by the specific line of business (Medicaid/SCHIP/Family Care, or Hoosier Care Connect) to determine if PA is required and which guideline is used for the case review. To access the PA lookup tool, go to providers.anthem.com/in, and select the precertification lookup tool under the Claims drop-down menu.

Contracted providers can also access the provider look up tool via Availity Essentials at Availity.com, selecting the Payer Spaces then select the pre-cert look up tool tile.

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
• Indiana PathWays for Aging — 833-412-4405

Effective October 1, 2024, the below CPT^® codes will require prior authorization (PA). All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The PA lookup tool allows care providers to search codes by the specific line of business to determine if PA is required and which guideline is utilized for the case review. To access the PA lookup tool, go to providers.anthem.com/in, and select the Precertification Lookup Tool under the Claims drop-down.

Contracted care providers can also access the provider look up tool via Availity Essentials at Availity.com select Payer Spaces, then select the Precertification Lookup Tool tile.

For assistance with questions regarding the PA requirement change, 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

Effective December 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem 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 precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider. Choose the Select a State ribbon and then find on the Resources tab. Contracted providers can also access Availity.com. 

The Federal Employee Program^® (FEP) offers a quality reimbursement program for providers. Coding for CPT^® II category codes for A1c results, blood pressure readings, and the first prenatal visit are reimbursed at $10 per code.

The program has been a success in improving HEDIS^® scores and data collection. The FEP Quality Reimbursement Program for PPO providers was revised as noted below effective May 12, 2023.

Revisions to CPT II category II code requirements for $10 reimbursement:

• Only professional HCFA billing providers
• Only these six places of service codes are applicable:
  • 2 — telehealth not home
  • 10 — telehealth home
  • 11 — office
  • 12 — home
  • 17 — walk-in clinic
  • 20 — urgent care
• Only a specific diagnosis code that coordinates with the applicable CPT II code

Submitting the claim

Submit the CPT II code in field 24 of the HCFA 1500 with a charge of $10.

Use the applicable CPT II code, place of service code, and diagnosis code according to the information below.

Blood pressure — systolic and diastolic readings

Reimbursable DX codes: I10, I11.9, I12.9, I13.10, I15, I15.1, I15.8, I15.9, I16.0, I16.1, I16.9

Hemoglobin A1c

Reimbursable DX codes: E10.8, E10.9, E11.8, E11.9

First prenatal visit

The first prenatal visit date of service must be on the claim (field 24A HCFA 1500) with the appropriate code.

Reimbursable DX codes: Maternity-related diagnosis code

For additional information about the FEP Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.

Anthem is excited to announce the development of the Blue National Physician Performance Dataset. This initiative is a collaborative approach between Blue Cross Blue Shield Association, Blue Health Intelligence (BHI), and Motive Medical Intelligence (MMI) to develop a consistent national approach to evaluating physicians at the National Provider Identifier (NPI) level that incorporates measures of quality of care, appropriateness of care, and cost/efficiency of care.

Effective January 1, 2025, Anthem may incorporate the Blue National Physician Performance Dataset in various ways, including but not limited to:

• Providing special opportunities to participate in product offerings.
• When members contact Anthem with requests for referral options.
• Developing provider designations in provider directory (FindCare) tools.
• Enhancing existing tools in FindCare and Cost Finder, such as Personalized Match, that assist members with identifying or sorting providers.

For more information on how physicians are evaluated within each of the three categories (quality, appropriateness, and cost), you can view the Blue National Physician Performance Dataset Evaluation Method.

If you have any questions about the Methodology or your score, contact your local provider relationship management representative

The specialty pharmacy updates for 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.

The inclusion of a National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Effective for dates of service on or after December 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.

* Oncology use is managed by Carelon Medical Benefits Management.

Site of care updates

Update: In the May 2024 edition of Provider News, we announced the site of care review requirements for the following drugs would be effective August 1, 2024. Please be advised that the following drugs were not implemented to have SOC requirements added.

Access our Clinical Criteria to view the complete information for these site-of-care updates.

Step therapy updates

Effective for dates of service on or after December 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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.

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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.

Prior authorization updates

Effective for dates of service on and after July 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will require prior authorization.

The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

Step therapy updates

Effective for dates of service on and after July 1, 2023, the following specialty pharmacy code from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal in addition to the current medical necessity review of the drug noted below.

Want to reduce administrative burden and help your patients save on prescription costs?

With real-time prescription benefit (RTPB), care providers can access patient-specific drug benefit information within the e-prescribing process. This functionality allows care providers to proactively identify barriers to cost and improve medication adherence.

"Prescription pickup rates have increased 3.2% and saved patients on average $40 per prescription with using real-time prescription benefit.” — Surescripts.²

When using real-time prescription benefit during e-prescribing, care providers can see patient-specific benefit information including:

• Formulary status of selected medication.
• Patient cost share of medication at a retail and mail order pharmacy.
• Up to five formulary drug alternatives.
• Coverage alerts, including prior authorization and step therapy.

Benefits you and your patients will experience when using RTPB:

• Clearer, faster information
• Opportunity to lower cost barriers
• Decreased administrative burden
• Reduced time to therapy
• Enhanced patient experience

How real-time prescription benefit works:

1. Prescriber enters prescription information through e-prescribing.
2. The e-prescribing system triggers a data call to the pharmacy benefit manager (PBM).
3. The PBM receives the real-time prescription benefit request.
4. The PBM delivers cost, formulary, and utilization information for the selected pharmacy back to the prescriber’s electronic health record (EHR).
5. Prescriber and patient make a choice together.

Help your patients save money on their prescriptions with EHR access to patient-specific drug coverage and out of pocket costs. Find out if your EHR vendor provides real-time prescription benefits information. There’s no charge for the service; however, you will need the latest version of your EHR.

Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about:

• Copayment/coinsurance requirements and their applicable drug classes.
• Drug lists and changes.
• Prior authorization criteria.
• Procedures for generic substitution.
• Therapeutic interchange.
• Step therapy or other management methods subject to prescribing decisions.
• Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner.