 Provider News KentuckyAugust 1, 2019 August 2019 Anthem Provider News - KentuckyAnthem Blue Cross and Blue Shield (Anthem) reviews and updates our online Provider Manuals annually. The updated manual is now available on our public provider website at anthem.com.
To view the provider manual, go to anthem.com > Provider > Provider Overview > Scroll down to “Enjoy Easy Access to Policies and Guidelines” and select “See Policies and Guidelines”. From the Policies and Guidelines landing page, there is a Provider Manual section with a link to Download Manual, as well as access previous versions and other manuals applicable to your state.
Anthem Blue Cross and Blue Shield (Anthem) has launched a new page on anthem.com to access Provider Manuals. This page delivers a more streamlined and easier user experience to access current and past Manuals (if applicable). To view the new page:
- Go to anthem.com, then Provider
- Go to Provider Overview
- Scroll down to Enjoy Easy Access to Policies and Guidelines and select See Policies and Guidelines
- From the Policies and Guidelines landing page, go to the Provider Manual section
- There is a button to Download Manual, as well as access previous versions and other manuals applicable to your state
To help ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis, we review clinical information, including lab results, treatment and medical management, in the medical records submitted. In order to conduct the review accurately and consistently, our review process for sepsis diagnoses applies coding and documentation guidelines, in addition to the updated and most recent sepsis 3 clinical criteria, published in Journal of the American Medical Association, February 2016. Clinicians and facilities should apply the sepsis 3 criteria when determining at discharge if their patient’s clinical course supports the coding and billing of a diagnosis of sepsis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the sepsis 3 definition and criteria.
The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on June 6, 2019 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
Below are new medical policies or clinical guidelines
NOTE *Precertification required
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Title
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Information
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Effective Date
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*GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
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• The use of bronchial gene expression classification for the diagnostic evaluation of lung cancer in individuals with pulmonary lesions is considered Investigational and Not Medically Necessary (INV&NMN)
-No specific code for bronchial gene expression classifiers such as Percepta by Veracyte; listed 81479 NOC
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11/1/19
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SURG.00153 Cardiac Contractility Modulation Therapy
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· The use of cardiac contractility modulation therapy is considered Investigational and Not Medically Necessary (INV&NMN) for all indications, including but not limited to heart failure.
· Existing codes 0408T-0418T and associated ICD-10-PCS codes will be denied Investigational and Not Medically Necessary (Inv&NMN) for all diagnoses
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11/1/19
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*MED.00129 Gene Therapy for Spinal Muscular Atrophy
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• A one-time infusion of onasemnogene abeparvovec-xioi (Zolgensma®) is considered Medically Necessary (MN) in individuals with spinal muscular atrophy (SMA) type 1 when all of the criteria are met
• Onasemnogene abeparvovec-xioi is considered Investigational and Not Medically Necessary (INV&NMN) when criteria are not met, including for repeat infusions, and for all other indications
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6/13/19
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These current Clinical Guidelines and/or Medical policies were reviewed and updates were approved.
NOTE *Precertification required
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Title
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Change
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Effective date
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*CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
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• Content moved from GENE.00021
• Investigational and Not Medically Necessary (INV&NMN) changed to Not Medically Necessary (NMN) as a result of Medical Policy to Clinical UM Guideline transition
• No other change to clinical indications
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9/4/19
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CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus
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• Content moved from SURG.00106
• Revised Medically Necessary (MN) indications to include IMC
• Added cryoablation to Medically Necessary (MN) criteria
• Investigational and Not Medically Necessary (INV&NMN) changed to Not Medically Necessary (NMN) as a result of Medical Policy to Clinical UM guideline transition
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9/4/19
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*DME.00037 Cooling Devices and Combined Cooling/Heating Devices
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• Added devices that combine cooling and vibration to the Investigational and Not Medically Necessary (INV&NMN) statement
-No specific code for vibration devices; added to E1399 NOC
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11/1/19
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LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests
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• Added Mediator Release Test to Investigational and Not Medically Necessary (INV&NMN) statement
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11/1/19
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LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
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• Clarified Investigational and Not Medically Necessary (INV&NMN) statement to include 4Kscore and AR-V7
-No specific code for AR-V7 protein biomarker testing, listed 81479 NOC
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11/1/19
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*OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis
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• Clarified Medical Necessity position statement criteria 2 through 4
• Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered Investigational and Not Medically Necessary (INV&NMN) for all indications
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11/1/19
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SURG.00011 Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting
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Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting
-Codes 65778, 65779, 65780, V2790 for ocular amniotic membrane application will be allowed for appropriate diagnosis codes
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11/1/19
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SURG.00045 Extracorporeal Shock Wave Therapy
Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions
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• Added erectile dysfunction, Peyronie’s disease and wound repair to the Investigational and Not Medically Necessary (INV&NMN) statement
• Revised title
-Added existing codes 0512T, 0513T for wounds and 55899 NOC for male genital ESWT; will deny as Investigational and Not Medically Necessary (Inv&NMN)
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11/1/19
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SURG.00121 Transcatheter Heart Valve Procedures
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• Added Investigational and Not Medically Necessary (INV&NMN) statement to address use of transcatheter tricuspid valve repair or replacement for all indications
-Added CPT codes 0544T, 0545T effective 07/01/19 for mitral and tricuspid valve procedures Investigational and Not Medically Necessary (Inv&NMN)
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11/1/19
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Effective November 1, 2019, the following MCG care guideline 23rd edition customization will be implemented for Chemotherapy, Inpatient & Surgical Care (W0162) for adult patients. This customization provides specific criteria and guidance on the following:
- Revised Clinical Indications for admission and added examples for:
- o Aggressive hydration needs that cannot be managed in an infusion center
- o Prolonged marrow suppression
- Added Regimens that cannot be managed as an outpatient with examples
Click here to view the summary of MCG 23RD edition customizations.
For questions, please contact the provider service number on the back of the member's ID card.
Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.
Oncologic Imaging Guideline contains updates to the following:
- Colorectal cancer, germ cell tumors, kidney cancer, multiple myeloma, prostate cancer and cancers of unknown primary / cancers not otherwise specified,
- Added new sections on hepatobiliary cancer and suspected metastases
- Added allowance for MRI and/or MRCP for diagnostic workup of hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma
- Added allowance for PET “When standard imaging prior to planned curative surgery for cholangiocarcinoma has been performed and has not demonstrated metastatic disease”
Vascular Imaging Guideline contains updates to the following:
- Brain, Head and Neck: Aneurysm - intracranial, Aneurysm - extracranial, Arteriovenous malformation (AVM) and fistula (AVF), Fibromuscular dysplasia, Hemorrhage - intracranial, Stenosis or occlusion - extracranial, Stenosis or occlusion - intracranial, stroke and Venous thrombosis or compression - intracranial
- Chest: Acute aortic syndrome, Aortic aneurysm, Pulmonary artery hypertension
- Abdomen and Pelvis: Acute aortic syndrome, Aneurysm of the abdominal aorta or iliac arteries, Hematoma/hemorrhage within the abdomen or unexplained hypotension, Renal artery stenosis (RAS)/Renovascular hypertension, Venous thrombosis or compression – intracranial, Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
- Upper Extremity: Peripheral arterial disease, Venous thrombosis or occlusion
- Lower Extremity: Added physiologic testing for peripheral arterial disease and further defined indications for classic presenting symptoms of lower extremity peripheral arterial disease
- Added arterial ultrasound guideline content
- Aligned peripheral arterial ultrasound with advanced vascular imaging criteria
Imaging of the Heart Guideline contains updates to the following:
- Blood Pool Imaging: Changes address appropriate evaluation and surveillance of LV function in patients following cardiac transplantation. Additional language is more restrictive based on the literature and aligns with the resting transthoracic echocardiography guideline.
- Cardiac CT: Quantitative evaluation of coronary artery calcification has been revised with new more expansive language based on review of the literature.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 800-554-0580, Monday–Friday, 8:30 a.m.–7:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.
. Effective for dates of service on and after July 14, 2019, the following updates will apply to the AIM Advanced Oncologic Imaging Clinical Appropriateness Guideline.
Prostate Cancer
Added criteria for the appropriate use of PET-CT with the radiotracers Axumin and 11-Choline, establishing the position of this test in the care continuum for prostate cancer primarily related to biochemical recurrence
Neuroendocrine Tumors
Added criteria for the appropriate use of PET-CT with the radiotracer DOTA-TATE, establishing the position of this test in the care continuum for neuroendocrine tumors
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number 800-554-0580, Monday–Friday, 8:30 a.m.–7:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.
Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Radiation Oncology: Proton Beam Therapy Clinical Appropriateness Guideline.
- Sinonasal cancer: Added criteria and diagnosis codes for locally advanced sinonasal cancer when tumor involves base of skull and proton beam therapy is needed to spare orbit, optic nerve, optic chiasm, or brainstem
- Ocular Melanoma: Removed tumor size restrictions for treating melanoma of the uveal tract
- Pediatric tumors: Clarified proton beam therapy appropriate for all pediatric tumors requiring radiation therapy
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 800-554-0580, Monday–Friday, 8:30 a.m.–7:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.
Please note, this program does not apply to FEP or National Accounts.
Beginning with dates of service on or after November 1, 2019, new Inter-professional CPT codes 99451 and 99452 are not eligible for reimbursement when they are reported with another service or reported as a stand-alone service. These codes have been added to policy section 1 of the Bundled Services and Supplies reimbursement policy.
View reimbursement policies online at anthem.com
Click here to find Anthem’s professional and facility reimbursement policies online.
Our Frequency Editing policy applies frequency maximums per day and/or per date span within the same grouping which may be based on the CMS’s MUEs, industry standards, and/or code description. Beginning with dates of service November 1, 2019, maximum units per day may be based on claims data analysis.
View reimbursement policies online at anthem.com
Click to find Anthem’s professional and facility reimbursement policies online.
Below are clinical criteria and prior authorization updates were endorsed at the May 17, 2019 Clinical Criteria meeting. Click here to access the Clinical Criteria page on anthem.com
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. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Revised Clinical Criteria effective June 10, 2019
The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
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Clinical or Coverage Guideline
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Clinical Criteria
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Clinical Criteria Name
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Drug(s)
|
HCPCS or CPT Code(s)
|
|
CG-DRUG-106
|
ING-CC-0092
|
Adcetris (brentuximab)
|
Adcetris
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J9042
|
|
CG-DRUG-38
|
ING-CC-0094
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Alimta (pemetrexed)
|
Alimta
|
J9305
|
|
CG-DRUG-42
|
ING-CC-0096
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Asparagine Specific Enzymes
|
Erwinaze, Asparaginase, Oncaspar
|
J9019, J9020, J9266
|
|
CG-DRUG-63
|
ING-CC-0104
|
Leucovorin and Levoleucovorin agents
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Fusilev, Khapzory
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J0641, C9043, J3490
|
|
CG-DRUG-66
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ING-CC-0105
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Vectibix (panitumumab)
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Vectibix
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J9303
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|
CG-DRUG-72
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ING-CC-0110
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Perjeta (pertuzumab)
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Perjeta
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J9306
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|
CG-DRUG-96
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ING-CC-0115
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Kadcyla (ado-trastuzumab)
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Kadcyla
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J9354
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|
CG-DRUG-98
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ING-CC-0116
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Bendamustine agents
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Bendeka, Treanda, Belrapzo
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J9034, J9033, C9042, J9999
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|
DRUG.00046
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ING-CC-0119
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Yervoy (ipilimumab)
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Yervoy
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J9228
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|
DRUG.00053
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ING-CC-0120
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Kyprolis (carfilzomib)
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Kyprolis
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J9047
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|
DRUG.00063
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ING-CC-0122
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Arzerra (ofatumumab)
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Arzerra
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J9302
|
|
DRUG.00067
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ING-CC-0123
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Cyramza (ramucirumab)
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Cyramza
|
J9308
|
|
DRUG.00071
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ING-CC-0124
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Keytruda (pembrolizumab)
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Keytruda
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J9271
|
|
DRUG.00075
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ING-CC-0125
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Opdivo (nivolumab)
|
Opdivo
|
J9299
|
|
DRUG.00107
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ING-CC-0129
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Bavencio (avelumab)
|
Bavencio
|
J9023
|
Revised Clinical Criteria effective September 1, 2019
The following new clinical criteria were reviewed with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
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Clinical or Coverage Guideline
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Clinical Criteria
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Clinical Criteria Name
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Drug(s)
|
HCPCS or CPT Code(s)
|
|
CG-DRUG-100
|
ING-CC-0085
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Actimmune (interferon gamma-1B)
|
Actimmune
|
J9216
|
|
CG-DRUG-101
|
ING-CC-0090
|
Ixempra (ixabepilone)
|
Ixempra
|
J9207
|
|
CG-DRUG-102
|
ING-CC-0091
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Lartruvo (olaratumab)
|
Lartruvo
|
J9285
|
|
CG-DRUG-49
|
ING-CC-0098
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Doxorubicin Hydrochloride Liposome
|
Lipodox, Doxorubicin hydrochloride liposomal, Doxil
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Q2049, Q2050
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|
CG-DRUG-50
|
ING-CC-0099
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Abraxane (paclitaxel protein-bound)
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Abraxane
|
J9264
|
|
CG-DRUG-51
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ING-CC-0100
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Istodax (romidepsin)
|
Istodax
|
J9315
|
|
CG-DRUG-62
|
ING-CC-0103
|
Faslodex (fulvestrant)
|
Faslodex
|
J9395
|
|
CG-DRUG-67
|
ING-CC-0106
|
Erbitux (cetuximab)
|
Erbitux
|
J9055
|
|
CG-DRUG-68
|
ING-CC-0107
|
Bevacizumab agents (Avastin, Mvasi)
|
Avastin, Mvasi
|
J9035, Q5107
|
|
CG-DRUG-70
|
ING-CC-0108
|
Halaven (eribulin)
|
Halaven
|
J9179
|
|
CG-DRUG-71
|
ING-CC-0109
|
Zaltrap (ziv-aflibercept)
|
Zaltrap
|
J9400
|
|
CG-DRUG-75
|
ING-CC-0111
|
Nplate (romiplostim)
|
Nplate
|
J2796
|
|
CG-DRUG-77
|
ING-CC-0112
|
Xofigo (Radium Ra 223 Dichloride)
|
Xofigo
|
A9606, 79101
|
|
CG-DRUG-80
|
ING-CC-0114
|
Jevtana (cabazitaxel)
|
Jevtana
|
J9043
|
|
CG-DRUG-99
|
ING-CC-0117
|
Empliciti (elotuzumab)
|
Empliciti
|
J9176
|
|
CG-THER-RAD-03
|
ING-CC-0118
|
Radioimmunotherapy: Zevalin; azedra; Lutathera
|
Zevalin, Azedra, Lutathera
|
79403, A9543, 79101, A9699, C9408, A9513
|
|
DRUG.00062
|
ING-CC-0121
|
Gazyva (obinutuzumab)
|
Gazyva
|
J9301
|
|
DRUG.00076
|
ING-CC-0126
|
Blincyto (blinatumomab)
|
Blincyto
|
J9039
|
|
DRUG.00082
|
ING-CC-0127
|
Darzalex (daratumumab)
|
Darzalex
|
J9145
|
|
DRUG.00088
|
ING-CC-0128
|
Tecentriq (atezolizumab)
|
Tecentriq
|
J9022
|
|
DRUG.00109
|
ING-CC-0130
|
Imfinzi (durvalumab)
|
Imfinzi
|
J9173
|
|
CG-DRUG-113
|
ING-CC-0131
|
Besponsa (inotuzumab ozogamicin)
|
Besponsa
|
J9229
|
|
DRUG.00112
|
ING-CC-0132
|
Mylotarg (gemtuzumab ozogamicin)
|
Mylotarg
|
J9203
|
|
DRUG.00118
|
ING-CC-0133
|
Aliqopa (copanlisib)
|
Aliqopa
|
J9057
|
|
MED.00106
|
ING-CC-0134
|
Provenge (Sipuleucel-T)
|
Provenge
|
Q2043
|
|
CG-MED-67
|
ING-CC-0135
|
Melanoma Vaccines
|
Imlygic
|
J9325, J3590
|
|
CG-DRUG-53
|
ING-CC-0136
|
Drug dosage, frequency, and route of administration
|
N/A
|
N/A
|
|
CG-DRUG-01
|
ING-CC-0141
|
Off-Label Drug and Approved Orphan Drug Use
|
N/A
|
N/A
|
Revised Clinical Criteria effective November 1, 2019
The following current and new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0048 Spinraza (nusinersen)
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0113 Sylvant (siltuximab) [previously CG-DRUG-79]
New Clinical Criteria effective November 1, 2019
The following clinical criteria are new.
- ING-CC-0137 Cablivi (caplacizumab-yhdp)
- ING-CC-0138 Asparlas (calaspargase pegol-mknl)
- ING-CC-0139 Evenity (romosozumab-aqqg)
- ING-CC-0140 Zulresso (brexanolone)
Expanded specialty pharmacy prior authorization list
Effective for dates of service on and after November 1, 2019, the following non-oncology specialty pharmacy codes from current clinical criteria 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.
Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
NDC Code(s)
|
Drug
|
|
ING-CC-0050
|
J3490
J3590
|
00074-2042-01 00074-2042-02
|
Skyrizi™
|
In the June newsletter we announced the transition of the medical non-oncology specialty drug review process from AIM Specialty Health® (AIM) to Anthem Blue Cross and Blue Shield (Anthem)’s medical specialty drug review team, effective June 15, 2019. Here’s a reminder of the changes.
What has changed?
- Beginning June 15, 2019 all requests, regardless of service date, providers need to submit a new prior authorization request by contacting Anthem’s medical specialty drug review team:
- o by phone at 1-833-293-0659 or
- o by fax at 1-888-223-0550 or
- o Online access at Availity.com available 24/7.
- All inquiries about an existing request (initially submitted to AIM or Anthem), peer-to-peer review, or reconsideration are being managed by Anthem’s medical specialty drug review team.
What has not changed?
- AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.
- Clinical criteria for medical non-oncology specialty drugs continues to reside on the Clinical Criteria page on anthem.com
- Post Service Clinical Coverage Reviews and Grievance and Appeals process and teams have not changed.
Here is a summary of the medical specialty drug changes, beginning June 15, 2019:
|
Action
|
Contact
|
|
Submit a new prior authorization request for medical specialty drug reviews
|
Call Anthem at 1-833-293-0659
OR
Fax us at 1-888-223-0550 for
OR
Access online at www.availity.com available 24/7
|
|
Inquire about an existing request (initially submitted to AIM or Anthem), peer-to-peer review, or reconsideration
|
Call Anthem at 1-833-293-0659
|
Visit anthem.com/pharmacyinformation for more information on:
- 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 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.
Enhancements have been made to the Availity Portal that will now allow you to access more service types when using the Eligibility and Benefits Inquiry tool and will also allow us to share even more valuable information with you electronically.
You may have already noticed new additions to service types, including:
- Medically related transportation.
- Long-term care.
- Acupuncture.
- Respite care.
- Dermatology.
- Sleep study therapy (found under diagnostic medical).
- Allergy testing.
Note, although there is an extensive list of available benefit types available when submitting an eligibility and benefits request, these types do vary by payer.
Here are some important points to remember when selecting service types:
- The benefit/service type field is populated with the last benefit type you selected. If you don’t see a specific benefit in the results, submit a new request and select the specific benefit type/service code.
- You have the ability to inquire about 50 patients at one time using the Add Multiple Patients feature.
501372MUPENMUB (Policy 19-001, effective 10/01/19)
Anthem Blue Cross and Blue Shield (Anthem) Medicare Advantage allows reimbursement for presumptive and definitive drug screening services. In certain circumstances, Anthem Medicare Advantage allows reimbursement for presumptive drug testing by instrumented chemistry analyzers and definitive drug screening services for the same member provided on the same day by a reference laboratory.
Definitive drug testing may be done to confirm the results of a negative presumptive test or to identify substances when there is no presumptive test available. Provider’s documentation and member’s medical records should reflect that the test was properly ordered and support that the order was based on the result of the presumptive test.
In the event a reference lab (POS = 81) performs both presumptive and definitive tests on the same date of service, records should reflect that the ordering/treating provider issued a subsequent order for definitive testing based on the results of the presumptive tests.
For additional information, refer to the Drug Screen Testing reimbursement policy at www.anthem.com/medicareprovider.
501120MUPENMUB
Currently, providers submit various pre-service requests to AIM Specialty Health ® (AIM). As part of our ongoing quality improvement efforts for outpatient diagnostic imaging services, cardiac procedures and sleep studies, AIM may request documentation to support the clinical appropriateness of certain requests.
When requested, providers should verify information by submitting documentation from the medical record and/or participating in a pre-service consultation with an AIM physician reviewer. If medical necessity is not supported, the request may be denied as not medically necessary.
Should you have any questions, please call the Provider Services number on the back of the member ID card.
501337MUPENMUB
Anthem Blue Cross and Blue Shield offers special needs plans (SNPs) to people eligible for either Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNPs include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums. As you are aware, CMS regulations protect SNP members from balance billing.
Providers who are contracted for SNPs are required to take annual training to stay current on plan benefits and requirements, including coordination-of-care and model-of-care elements. Providers contracted for our SNPs received notices in the first quarter of 2019 containing information for online, self-paced training through our training site hosted by SkillSoft. Each provider contracted for our SNPs is required to complete this annual training and select the attestation stating they have completed the training. Attestations can be completed by individual providers or at the group level with one signature.
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As we prepare for the potential regulatory-proposed standards for electronic attachments, Anthem Blue Cross and Blue Shield Medicaid (Anthem) will be implementing X12 275 electronic attachment transactions (version 5010) for claims.
Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reducing processing time overall.
Anthem and Availity will pilot electronic data interchange batch electronic attachments with previously selected providers. Both solicited and unsolicited attachments will be included in our pilots.
Attachment types
- Solicited attachments: The provider sends a claim and the payer determines there is not enough information to process the claim. The payer will then send the provider a request for additional information (currently done via letter). The provider can then send the solicited attachment transaction, with the documentation requested, to process the claim.
- Unsolicited attachment: When the provider knows that the payer requires additional information to process the claim, the provider will then send the X12 837 claim with the Paper Work Included segment tracking number. Then, the provider will send the X12 275 attachment transaction with the additional information and include the tracking number that was sent on the claim for matching.
What you can do
As we prepare for this change, you can help now by having conversations with your clearinghouse and/or electronic healthcare records vendor to determine their ability to set up the X12 275 attachment transaction capabilities.
In addition, you should be on the lookout for additional information and details about working with Anthem and Availity to send attachments via electronic batch.
Need up-to-date pharmacy information?
Log in to our provider website (https://mediproviders.anthem.com/ky) to access our Formulary, Prior Authorization form, Preferred Drug List and process information.
Have questions about the Formulary or need a paper copy?
Call our Pharmacy department at 1-855-661-2028. Pharmacy technicians are available Monday through Friday from 8 a.m. to 6 p.m. Eastern time/7 a.m. to 5 p.m. Central time.
Our Member Services representatives serve as advocates for our members. To reach Member Services, please call 1-855-690-7784 (TTY 711).
We continually update our provider directories to ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice — including updating your address and/or phone number, adding or deleting a physician from your practice, closing your practice to new patients, etc. — please notify us by completing the Provider Maintenance Form available at https://mediproviders.anthem.com/ky/pages/provider-forms.aspx. Thank you for your help and continued efforts in keeping our records up to date.
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