Anthem will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.

Visit anthem.com to locate the Provider Maintenance Form. Contact Provider Services if you have any questions.

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In January we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.

In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:

• Medical Policies and Clinical Guidelines
• Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)

Steps to access the Authorization Lookup application through Availity Payer Spaces

Access to the tool does not require an Availity role assignment.

1. Select Payer Spaces
2. Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu
3. Select the Applications tab
4. Select the Authorization Rules Lookup tile

Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:

• Tax ID
• National Provider Identifier (NPI)
• Member ID and birth date
• Member’s Group number or Contract Code
  (This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)
• CPT/HCPCS code

Give this new tool a try and discover how much this will improve the efficiency of your authorization process.

Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal.

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Please continue to check Medicaid Provider Communications & Updates on the provider website for the latest information, including:

• InterQual 2020.1 update
• New specialty pharmacy medical step therapy requirements-1
• New specialty pharmacy medical step therapy requirements-2
• Updates to AIM Clinical Appropriateness Guidelines for Advanced Imaging
• Sign up to receive email from Anthem Blue Cross and Blue Shield Medicaid

On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Medicaid. 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 August 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

CAHPS is an annual standardized survey conducted from January to May to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may get the survey. Providers directly impact the majority of questions used for scoring.

These questions are:

• When you needed care right way, how often did you get it?
• How often did you get an appointment for a check-up or routine care as soon as you needed it?
• How often was it easy to get the care, tests, or treatment you needed?
• How often did you get an appointment to see a specialist as soon as you needed it?
• How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
• How would you rate your primary care doctor?
• How would you rate the specialist you see most often?

To learn more about CAHPS and how you can improve the patient experience, review the CAHPS Overview training by visiting https://mediproviders.anthem.com/ky.

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Revised measures

• The former Well-Child Visits in the First 15 Months of Life (W15) measure was revised to Well‑Child Visits in the First 30 Months of Life (W30). It includes two indicators:
  • Well-child visits in the first 15 months — children who turned 15 months during the measurement year with six or more well-child visits
  • Well-child visits for ages 15 to 30 months — children who turn 30 months during the measurement year with two or more well-child visits
• The former Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) and Adolescent Well-Care Visits (AWC) measures have been combined into Child and Adolescent Well-Care Visits (WCV):
  • The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year

Key measure changes

• Controlling High Blood Pressure (CBP and CDC-CBP)
  Telephone visits, e-visits and virtual check-ins are now acceptable settings for blood pressure (BP) readings. Digital BP readings reported by the member are considered numerator compliant.
• Telehealth updates
  NCQA has updated telehealth guidance in 40 HEDIS^® measures for HEDIS measurement years 2020 and 2021. The purpose of these changes is to:
  • Support increased use of telehealth caused by the pandemic.
  • Align with guidance from Centers for Medicare & Medicaid Services and other stakeholders.

A list of the 40 measures can be found on the NCQA COVID-19 website at www.ncqa.org/covid.

New Medicaid measures

Kidney Health Evaluation for Patients With Diabetes (KED) — The percentage of members 18 to 85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a uACR identified by both a quantitative urine albumin test and a urine creatinine test with service days four or less days apart during the measurement year

Cardiac Rehabilitation (CRE) — The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation, or heart valve repair/replacement; four rates are reported:

• Initiation — The percentage of members who attended two or more sessions of cardiac rehabilitation within 30 days after a qualifying event
• Engagement 1 — The percentage of members who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event
• Engagement 2 — The percentage of members who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
• Achievement — The percentage of members who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event

Retired Medicaid measures

• Comprehensive Diabetes Care (CDC) retired sub-measures
  • Medical Attention for Nephropathy (retired for Commercial and Medicaid)
  • HbA1c control (< 7.0%) for a selected population
• Adult BMI Assessment (ABA)
• Medication Management for People With Asthma (MMA)
• Children’s and Adolescents’ Access to Primary Care Practitioners (CAP)

Measure change summary:

For a complete summary, go to https://tinyurl.com/NCQA-measures.

Anthem Blue Cross and Blue Shield Medicaid (Anthem) reviews the activities of the Food and Drug Administration (FDA)’s approval of drugs and biologics on a regular basis to understand the potential effects for our providers and members.

The FDA approves new drugs and biologics using various pathways. Recent studies on the effectiveness of drugs and biologics going through different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.

Here is a list of the approval pathways the FDA uses for drugs/biologics:

• Standard review — The standard review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public; watches for problems once drugs and biologics are available to the public; monitors drug/biologic information and advertising; and protects drug/biologic quality. Follow this link to learn more about the standard review process.

• Fast track — Fast track is a process designed to facilitate the development and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Follow this link to learn more about the fast track process.
• Priority review — A priority review designation means FDA’s goal is to take action on an application within six months. Follow this link to learn more about the priority review process.
• Breakthrough therapy — This process is designed to expedite the development and review of drugs/biologics which may demonstrate substantial improvement over available therapy. Follow this link to learn more about the breakthrough therapy review process. 
• Orphan review — This refers to the review of drugs that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Follow this link to learn more about the orphan drug review process. 
• Accelerated approval — These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. To learn more about the accelerated approval process, follow this link. 

New molecular entities approvals: January 2020 through August 2020

Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.

Anthem reviews the FDA-approved NMEs on a regular basis. To facilitate the decision-making process, we are providing a list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized.

Note: This information has no impact on our standard prior authorization/pre-certification process.

Source: www.fda.gov

On April 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for the some codes. Click here for more information about PN for UM AROW Item 1330.

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On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC (AMH Health). 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 September and October 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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This communication applies to the Medicaid and Medicare Advantage programs in Kentucky.

These updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging for claims with dates of service on and after March 14, 2021. Click here for more information about the updates to AIM Clinical Appropriateness Guidelines for Advanced Imaging.

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