To advance our operations towards a more digitally efficient model, when a care provider registers for electronic remittance advice (ERA/835), we will cease issuing paper remittances 30 days after the effective registration date. Care providers will receive their remittance electronically through ERA with the option to print copies via Availity Essentials as needed in the Remit Inquiry application located in Payer Spaces.

Some care providers, despite successful registration, continue to receive remittances in both electronic and paper formats. We are actively addressing this redundancy by discontinuing the issuance of printed remittances. As a result, care providers who have enrolled for ERA/835 but are still receiving paper remittances will begin noticing a decrease in these paper transactions starting in late August.

If you have yet to register for ERA and wish to switch to electronic remittance reception, we recommend that you configure your ERA settings through Availity Essentials or by working with your existing clearinghouse vendor. In the interests of facilitating electronic transactions, care providers interested in receiving electronic payments are encouraged to visit the EnrollSafe Enrollment Hub (payeehub.org).

This transition is part of our ongoing commitment to streamlining our procedures, enhancing customer experience, and promoting environmental sustainability.

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

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

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

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

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

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

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

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

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

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

* Denotes prior authorization required

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

* Denotes prior authorization required

Effective December 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

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

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

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

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

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

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

Submitting the claim

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

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

Blood pressure — systolic and diastolic readings

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

Hemoglobin A1c

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

First prenatal visit

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

Reimbursable DX codes: Maternity-related diagnosis code

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

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

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

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

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

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

The specialty pharmacy updates for Anthem are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

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

Prior authorization updates

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

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

Site of care updates

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

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

Step therapy updates

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

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

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

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed below will be included in our precertification review process.

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

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed below will be included in our precertification review process.

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

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

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

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

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

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

Benefits you and your patients will experience when using RTPB:

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

How real-time prescription benefit works:

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

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

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

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

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

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

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

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

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

Why is Timeliness of Prenatal Care important?

Timely prenatal care plays a vital role in the health of Anthem mothers and their babies. Pregnant women who do not receive early and adequate prenatal care run the risk of complications that may either be undetected or treated too late in pregnancy. This increases the possibility of adverse outcomes for both mother and baby

Refer to attachment to view full details