As communicated in the November 2023, provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical, and Radiation Therapy programs.

Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem for medical necessity determination. For Medicare Advantage, Anthem makes coverage determinations based on guidance from CMS including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Carelon Medical Benefits Management will continue to use criteria documented in Anthem Medical Policies and Clinical Guidelines listed in the table below. These clinical guidelines can be reviewed online at Availity.com.

Detailed prior authorization requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at Availity.com. Contracted and noncontracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.

Prior authorization review requirements

Carelon Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1, 2024, and after. For procedures that are scheduled to begin on or after April 1, 2024, all providers must contact Carelon Medical Benefits Management to obtain prior authorization for the following non-emergency modalities. Refer to the clinical guidelines on the microsite resource pages for complete code lists.

Note: The procedure list has been updated since the November notification.

To determine if prior authorization is needed for a member on or after April 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on Availity Essentials for prior authorization requests on an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management.

Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.

How to place a review request

Providers may place a prior authorization request online to Carelon Medical Benefits Management using the convenient online service via the ProviderPortal_SM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using clinical criteria.

Go to https://www.providerportal.com/ to register.

For more information

For resources to help your practice get started with the Radiology, Cardiology, Genetic Testing, Musculoskeletal, Surgical, and Radiation Oncology programs, go to:

• https://providers.carelonmedicalbenefitsmanagement.com/genetictesting
• https://providers.carelonmedicalbenefitsmanagement.com/cardiology/
• https://providers.carelonmedicalbenefitsmanagement.com/radiology/
• https://providers.carelonmedicalbenefitsmanagement.com/musculoskeletal/

Our special websites will help you learn more and will allow you to access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs.

For additional help, you can also call your local provider relationship management representative.

We value your participation in our network and look forward to working with you to help improve the health of our members — your patients.

Effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical and Radiation Oncology programs. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1, 2024, and after.

Members included in the new program

All FI, self -funded (ASO), HealthLink, and national members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of April 1, 2024. A separate notice will be published for Medicare Advantage, Medicare, and MA GRS.

Members of the following products are excluded: Medicaid, Medicare supplement, Federal Employee Program® (FEP®).

Pre-service review requirements

For procedures that are scheduled to begin on or after April 1, 2024, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including but not limited to the following non-emergency modalities. Please refer to the clinical guidelines on the microsite resource pages for complete code lists.

Please note: The procedure list has been updated since the November notification. All codes will only be reviewed for medical necessity for the requested service and not for site of care at this time. Vascular procedures will not require prior authorization for National members currently participating in the Carelon Medical Benefits Management Cardiology program.

To determine if prior authorization is needed for a member on or after April 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information.  Providers using the Interactive Care Reviewer (ICR) tool on Availity Essentials to pre-certify an outpatient procedure, will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortal_SM. ProviderPortal is available twenty-four hours a day, seven days a week, processing requests in real-time using clinical criteria. Go to providers.carelonmedicalbenefitsmanagement.com/ to register.

For more information

Go to https://providers.carelonmedicalbenefitsmanagement.com/genetictesting, https://providers.carelonmedicalbenefitsmanagement.com/cardiology/, https://providers.carelonmedicalbenefitsmanagement.com/radiology/, https://providers.carelonmedicalbenefitsmanagement.com/musculoskeletal/, https://providers.carelonmedicalbenefitsmanagement.com/surgicalprocedures/; for resources to help your practice get started with the Radiology, Expanded Cardiology, Genetic Testing, Musculoskeletal, Surgical, and Radiation Oncology programs. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs, or you can call your local Network Relations representative.

With your help, we can continually build towards a future of shared success.

You may submit all your prior authorizations in one application on Availity.com

You may already be submitting your prior authorizations through the Availity multi-payer Authorization application — taking advantage of the time savings and speed to care through digital authorization submissions. Beginning in February, you can submit your physical health prior authorizations through one Authorization application on Availity.com. 

You can still access the Interactive Care Reviewer (ICR) to review cases that were submitted through that application. You will also continue to use ICR to submit an appeal or authorization for Behavioral Health. 

Using the Availity Authorization application to submit your physical health prior authorizations will not be much different from the process you follow today. You may enjoy more intuitive screens or learn sooner if an authorization is required — but the digital submission process is still the very best way to submit your prior authorization and the fastest way to care for our members. 

Training is available 

If you aren’t already familiar with Availity Authorization, training is available. Select Availity Authorization Training to enroll for an upcoming live webcast or to access an on-demand recording.

Now, give it a try!

Accessing Availity for authorization is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, log on to Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals.

Summary: On December 11, 2023, and January 5, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised. or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

See the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

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

Note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective for dates of service on and after May 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management.

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access Carelon Medical Benefits Management’s ProviderPortal_SM 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 Carelon Medical Benefits Management via the Availity Essentials website at Availity.com.

For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after March 1, 2024, the following medication codes from current or new Clinical Criteria documents billed on medical claims require prior authorization.

Please note, inclusion of a national drug code on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

What if I need assistance:

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 855-661-2028.

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

Effective May 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 on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at the number on the back of the patient’s member ID card for assistance with PA requirements.

Effective May 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 on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at the number on the back of the patient’s member ID card for assistance with PA requirements.

Beginning with dates of service on or after June 1, 2024, the Related Coding section of Anthem’s Ambulance Transportation – Professional reimbursement policy will be updated to specify that Modifier X, which is used to indicate an intermediate stop at the physician’s office enroute to a hospital, will only apply as a destination modifier.

Modifier X should only be used as a destination code in the second position of the modifier designated field.

Beginning with dates of service on or after June 1, 2024, Anthem will update the Related Coding section in the Laboratory and Venipuncture Services – Professional and Facility reimbursement policy.

Since our last policy review, we have identified that the following language was inadvertently removed from the Modifier 26 comment in the Section II: Modifiers code list:

• When a professional provider has reported modifier 26 to procedure codes designated with NPFSRVF PC/TC indicators 3 or 9, the procedure will not be eligible for reimbursement.

This language will be reinserted, and impacted claims will automatically be reprocessed.

For specific policy details, visit the following reimbursement policy page at anthem.com/provider.

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 medically specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

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.

Inclusion of 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

Update: In the January 2024 edition of Provider News, we announced prior authorizations for the following drugs would be effective April 1, 2024. Please be advised that the prior authorization effective date for the drugs listed below will be May 1, 2024.

* Oncology use is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after June 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.

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

Quantity limit updates

Effective for dates of service on and after June 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Step therapy updates

Effective for dates of service on and after June 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.

Effective March 1, 2024, prescriptions for Botox currently filled by Accredo Specialty Pharmacy will transfer to BioPlus, which is CarelonRx, Inc.’s new specialty pharmacy that services Anthem members.

What happens next:

• If you have patients affected by this pharmacy change, BioPlus will contact you to request a new prescription, refill, or prior authorization.
• Current specialty prescriptions for Botox with open refills will automatically transfer to BioPlus.
• Impacted patients will receive a letter and a phone call, explaining this transition.
• There is nothing you or your patients need to do except speak with BioPlus when they call.
• Any new Botox medication you prescribe for Anthem members must be submitted to BioPlus Specialty Pharmacy, to their MedScripts Medical Pharmacy location, as follows:
  • Medscripts Medical Pharmacy
    1325 Mille Road Suite K  
    Greenville, SC 29607
  • NPI: 1780958744
  • Phone: 866-840-4067
  • Fax: 833-670-2942
• If you prefer, you still have the option to purchase and supply the Botox. In this case, you would bill Anthem for the drug and administration of the drug.

If you have any questions, please call your Anthem representative. With your help, we can continually build towards a future of shared success.

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.

Therapeutic duplications are defined as concurrent use of two or more drugs in the same therapeutic class for the same indication. Anthem’s prior authorization criteria does not allow for certain drugs to be used in combination with each other if the drugs are in the same therapeutic class.

Starting June 1, 2024, if multiple drugs are prescribed in the same therapeutic class for the therapeutic classes listed in the Therapeutic duplication category column in the table below, providers will be required to obtain a prior authorization for each drug.

Example drugs for each therapeutic class are listed below. For a complete list for drugs that may not be used in combination, you can access our drug lists and formulary policies by visiting Pharmacy Information for Providers | Anthem.com.

As a reminder, prior authorizations may be submitted through any of the following ways:

• Online: Submit the prior authorization requests online through the CoverMyMeds website (covermymeds.com). Electronic submission will allow care providers to check the status of the prior authorization request in real time.
• Fax: Download prior authorization forms from anthem.com and fax the completed forms to the number on the fax form.
• Phone: Call Provider Services at the number on the back of your patient’s member ID card. Submitting requests online or via fax is preferred.

If you have any questions regarding this notice, please contact Provider Services at the number on the back of your patient’s member ID card.

Update: In the February 2024 edition of Provider News, we announced prior authorizations for the following drugs would be effective May 1, 2024. Please be advised that the prior authorization effective date for the drugs listed below will be June 1, 2024.

Effective for dates of service on and after June 1, 2024, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Notification of specialty pharmacy medical step therapy updates

Effective June 1, 2024, the following Part B medications from the current Clinical Criteria Guidelines will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.

Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

Anthem’s in-office prospective programs are designed to encourage the comprehensive annual assessment of patients’ health and support the complete and accurate documentation and coding of active, present conditions assessed. Collecting accurate and complete diagnosis information helps to support proper treatment, care management, and patient care. Providers participating in these programs may have the opportunity to receive reimbursement for the additional administrative time associated with their participation.

Key takeaways:

• Enhanced provider-patient engagement through comprehensive annual assessments and individual care planning
• Streamlined workflows designed to reduce administrative time spent by a provider at the point of care, allowing the provider to focus their time on their patients 
• Patient-specific insights to support a comprehensive assessment and improvement in the accuracy and completeness of diagnosis data collected 

Additional information about the in-office prospective program based on last year’s data:

• Patients who did not receive an in-office prospective program had, on average, an MLR increase of 2% YoY.
• Patients who received a comprehensive in-office assessment via the in-office prospective programs had, on average, 0.3 HCCs² reported based on that encounter.
• Providers who actively participated in the in-office prospective programs received, on average, 2%–5% increase to their Persistent Condition Validation (PCV).

We are committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities.

This is a courtesy notice as there is no change to current status of Eylea HD in the Medical Step Therapy Program. The step criteria for anti-vascular endothelial growth factor (VEGF) inhibitors found in Clinical Criteria document CC-0072 will formally list Eylea HD as a preferred product.

Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.