CommercialApril 1, 2020
Information from Anthem for Care Providers about COVID-19
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April 1, 2020 April 2020 Anthem Provider News - KentuckyAdministrativeCommercialApril 1, 2020 Information from Anthem for Care Providers about COVID-19CommercialApril 1, 2020 Anthem continues focus on updates to our public provider websiteCommercialApril 1, 2020 Provider Transparency UpdateCommercialMarch 2, 2020 Anthem acquires Beacon Health OptionsPolicy UpdatesCommercialApril 1, 2020 MCG Care Guidelines 24th EditionProducts & ProgramsCommercialApril 1, 2020 HEDIS 2020 Federal Employee Program® medical record request requirementsCommercialApril 1, 2020 Anthem prior authorization updates for specialty pharmacy are available - April 2020CommercialApril 1, 2020 Anthem to delay most April 1, 2020 formulary list updates for commercial health plan pharmacy benefitCommercialMarch 1, 2020 Pharmacy information available at anthem.comState & FederalMedicare AdvantageApril 1, 2020 COVID-19 information from Anthem Blue Cross and Blue ShieldMedicare AdvantageApril 1, 2020 Medicare News - April 2020Medicare AdvantageApril 1, 2020 Medical drug benefit Clinical Criteria updates - November 2019Medicare AdvantageApril 1, 2020 Medical drug benefit Clinical Criteria updates - December 2019Medicare AdvantageApril 1, 2020 2020 Medicare risk adjustment provider trainingsMedicaidApril 1, 2020 Medicaid News - April 2020MedicaidApril 1, 2020 Disease Management can help you care for patients with chronic health care needsMedicaidApril 1, 2020 Use of Imaging Studies for Low Back Pain (LBP)MedicaidApril 1, 2020 Kentucky Health Information Exchange grant opportunityTo view this publication online:Visit https://providernews.anthem.com/kentucky/publications/april-2020-anthem-provider-news-kentucky-523 Or scan this QR code with your phone CommercialApril 1, 2020 Information from Anthem for Care Providers about COVID-19For the most up-to-date information from Anthem Blue Cross and Blue Shield about COVID-19, please bookmark/add to favorites Provider News Home and check back often. To view this article online:Or scan this QR code with your phone CommercialApril 1, 2020 Anthem continues focus on updates to our public provider websiteAt Anthem Blue Cross and Blue Shield (Anthem), we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of Q1 brings a few updates for the site at anthem.com:
To view this article online:Or scan this QR code with your phone CommercialApril 1, 2020 Provider Transparency UpdateA key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.” Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in the provider getting more referrals from Value-Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.
Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.
Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.
Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers, including any opportunities for improvement. For questions or support, please refer to your local Network Representative or Care Consultant. To view this article online:Visit https://providernews.anthem.com/kentucky/articles/provider-transparency-update-23-4484 Or scan this QR code with your phone CommercialMarch 2, 2020 Anthem acquires Beacon Health OptionsAnthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.
Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives. From the standpoint of our customers and providers at this time, it’s business as usual:
We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return. For more details, please see the press release.
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/anthem-acquires-beacon-health-options-6-4375 Or scan this QR code with your phone CommercialApril 1, 2020 MCG Care Guidelines 24th EditionEffective July 1, 2020, we will upgrade to the 24th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.
Goal Length of Stay (GLOS) Changes for Inpatient & Surgical Care (ISC) and Behavioral Health Care (BHC)
New Optimal Recovery Guidelines (ORGs) for Inpatient & Surgical Care (ISC) and New Behavioral Health Care (BHC) New Guidelines
Anthem Customizations to MCG care guideline 24th Edition Effective July 1, 2020, the following MCG care guideline 24th edition customizations will be implemented.
To view a detailed summary of customizations, visit the Medical Policies & Clinical UM Guidelines page, scroll down to Other Criteria section and select Customizations to MCG Care Guidelines 24th Edition.
For questions, please contact the Provider Services number on the back of the member's ID card. To view this article online:Visit https://providernews.anthem.com/kentucky/articles/mcg-care-guidelines-24th-edition-3-4498 Or scan this QR code with your phone CommercialApril 1, 2020 UPDATE: Notice of changes to the AIM Musculoskeletal Program prior authorization requirementsThe March 2018 edition of the Network Update previously announced that AIM would review level of care and expected length of stay. As you know, AIM Specialty Health® (AIM) administers the musculoskeletal program. The musculoskeletal program includes the medical necessity review of certain surgeries of the spine and joints, as well as interventional pain treatment for Commercial fully insured Anthem members and some ASO groups.
Effective May 1, 2020, AIM will add the additional review of level of care and expected length of stay for medical necessity using AIM clinical guidelines for requests received on or after May 1, 2020.
Providers should continue to submit prior authorization review requests to AIM using one of the following ways:
In addition, AIM has developed an educational website to help your practice get started with the musculoskeletal and pain management program.
For questions, please contact the provider number on the back of the member ID card. To view this article online:Or scan this QR code with your phone CommercialApril 1, 2020 HEDIS 2020 Federal Employee Program® medical record request requirementsCentauri Health Solutions is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers, and ask that you respond to the detailed requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe. Centauri Health will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary).
We ask that you please promptly comply within five (5) business days of the record requests.
If you have any questions, please contact Ify Ifezulike with Blue Cross Blue Shield Federal Employee Program at (202) 626-4839 or Mary Kay Sander with Centauri at (636) 333-9145. To view this article online:Or scan this QR code with your phone CommercialApril 1, 2020 Anthem prior authorization updates for specialty pharmacy are available - April 2020Prior authorization updates Effective for dates of service on and after July 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
To access the clinical criteria document information please visit https://www11.anthem.com/pharmacyinformation/clinicalcriteria.html.
Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.
Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are in italics.
* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.
Step therapy updates
Effective for dates of service on and after July 1, 2020, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process.
Orencia will be the non-preferred agent for rheumatoid arthritis, polyarticular juvenile idiopathic arthritis and psoriatic arthritis. The table below will assist you in identifying the applicable preferred agents and clinical criteria.
To access the clinical criteria document information please visit https://www11.anthem.com/pharmacyinformation/clinicalcriteria.html.
Rheumatoid Arthritis (RA)
Polyarticular Juvenile Idiopathic Arthritis (PJIA)
Psoriatic Arthritis (PsA)
To view this article online:Or scan this QR code with your phone CommercialApril 1, 2020 Anthem to delay most April 1, 2020 formulary list updates for commercial health plan pharmacy benefitIn light of the current situation with COVID-19, we have decided to delay the implementation of many of the previously-communicated formulary changes scheduled for April 1, 2020.
The changes listed below will still go into effect on April 1, 2020:
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans. To view this article online:Or scan this QR code with your phone CommercialMarch 1, 2020 Pharmacy information available at anthem.comVisit anthem.com/pharmacyinformation for more information on:
The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. To view this article online:Or scan this QR code with your phone Medicare AdvantageApril 1, 2020 COVID-19 information from Anthem Blue Cross and Blue ShieldClick here for more information about the COVID-19 Virus Talking Points for Medicare Advantage.
To view this article online:Or scan this QR code with your phone Medicare AdvantageApril 1, 2020 Medicare News - April 2020Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/medicare-news-april-2020-4526 Or scan this QR code with your phone Medicare AdvantageApril 1, 2020 Medical drug benefit Clinical Criteria updates - November 2019On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
507833MUPENMUB
To view this article online:Or scan this QR code with your phone Medicare AdvantageApril 1, 2020 Medical drug benefit Clinical Criteria updates - December 2019On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.*
* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.
508037MUPENMUB To view this article online:Or scan this QR code with your phone Medicare AdvantageApril 1, 2020 2020 Medicare risk adjustment provider trainingsThe Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield (Anthem) offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.
Medicare Risk Adjustment and Documentation Guidance (General)
For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:
Note: Dates may be modified due to holiday scheduling.
Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)
For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:
507941MUPENMUB
To view this article online:Or scan this QR code with your phone MedicaidApril 1, 2020 Medicaid News - April 2020Please continue to check Medicaid Provider Communications & Updates on the provider website for the latest information, including:
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/medicaid-news-april-2020-1-4546 Or scan this QR code with your phone MedicaidApril 1, 2020 Disease Management can help you care for patients with chronic health care needsDisease Management programs are designed to assist PCPs and specialists in caring for members with chronic health care needs. Anthem Blue Cross and Blue Shield Medicaid provides members with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications for members.
Who is eligible?
Disease Management case managers provide support to members with:
Our case managers use member-centric motivational interviewing to identify and address health risks such as tobacco use and obesity to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.
We welcome your referrals. To refer a member to Disease Management:
Your input and partnership are valued. Once your patient is enrolled, you will be notified by the assigned Disease Management case manager. You can also access your patient’s Disease Management care plan, goals and progress at any time via the Availity Portal through Patient360.
We are happy to answer any questions. Our registered nurse case managers are available Monday to Friday from 8:30 a.m. to 5:30 p.m. local time, and our confidential voicemail is available 24 hours a day, 7 days a week. To view this article online:Or scan this QR code with your phone MedicaidApril 1, 2020 Use of Imaging Studies for Low Back Pain (LBP)The HEDIS® measure, Use of Imaging Studies for Low Back Pain (LBP), analyzes the percentage of patients 18 to 50 years of age during the measurement year with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is used to determine whether imaging studies are overused to evaluate members with low back pain. The measure is an inverted rate. A higher score indicates appropriate treatment of low back pain.
Clinical guidelines for treating patients with acute low back pain recommend against the use of imaging in the absence of red flags (in other words, indications of a serious underlying pathology such as a fracture or tumor). Unnecessary or routine imaging is problematic because it is not associated with improved outcomes and exposes patients to unnecessary harms such as radiation exposure and further unnecessary treatment.
Measure exclusions
Helpful tips Hold off on doing imaging for low back pain within the first six weeks, unless red flags are present.
Consider alternative treatment options prior to ordering diagnostic imaging studies, such as:
Other available resources:
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/use-of-imaging-studies-for-low-back-pain-lbp-4550 Or scan this QR code with your phone MedicaidApril 1, 2020 Kentucky Health Information Exchange grant opportunityIn collaboration with the Department for Medicaid Services and the Kentucky Health Information Exchange (KHIE), Anthem Blue Cross and Blue Shield Medicaid (Anthem) is offering participating Anthem providers the opportunity to apply for a grant to help offset the costs associated with connecting to KHIE. If approved, providers may be awarded up to $2,000, per tax identification number and/or business entity, until all grant funds up to $100,000 are depleted. Applications will be accepted through June 30, 2020.
To apply, visit the Anthem provider website. The application and instructions are under News and Announcements.
If you have questions, please contact your Network Relations Consultant. To view this article online:Or scan this QR code with your phone | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||