Provider News MaineApril 2023 Provider News - Maine Contents Products & Programs | Anthem Blue Cross and Blue Shield | Commercial | March 31, 2023 Let’s VaccinateState & Federal | Anthem Blue Cross and Blue Shield | Medicare Advantage | March 31, 2023 E-visits
Notices of material changes/amendments to contract may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements. In this issue, please reference the following articles: - Update to Claim Payment Dispute process
- Genetic testing CPT code list update for Carelon Medical Benefits Management (formerly AIM Specialty Health)
- Expansion of Carelon Medical Benefits Management, Inc. cardiology, genetic testing, and radiology programs effective August 1, 2023
- Bundled Services and Supplies — Professional
- Notification Regarding Reimbursement Changes to COVID-19 Vaccine Administration
Administrative | Anthem Blue Cross and Blue Shield | Commercial | March 31, 2023 Notice of material change/amendment to contract Update to Claim Payment Dispute processAnthem Blue Cross and Blue Shield (Anthem) is updating language to the Claim Payment Dispute process outlined in our Provider Manual. Providing clearer timelines will assist in your understanding of the processes for resolving disputes when you disagree with an initial claim payment decision. The information below will be reflected in the next Provider Manual update later this year. Effective July 1, 2023, if you disagree with the outcome of a claim, a Claim Payment Reconsideration, the first step in the Claim Payment Dispute process, must be submitted within 365 days from the date on the EOP unless otherwise required by State law or your Provider or Facility Agreement. If you disagree with the outcome of the Claim Payment Reconsideration determination, a Claim Payment Appeal, the second step in the Claim Payment Dispute process, must be submitted within 90 days from the date of the determination of the Claim Payment Reconsideration. Except in cases where the Provider or Facility presents evidence of an extenuating circumstance, Anthem will not consider requests submitted outside procedures set forth above. If a care provider submits a Claim Payment Reconsideration or Claim Payment Appeal outside the time frames above without evidence of an extenuating circumstance, the request is deemed ineligible and will not be considered. In such cases, care providers may not bill members for services rendered. Submitting a dispute The preferred method for submitting both Reconsiderations and Claim Payment Appeals is online through the “Disputes” function in Availity Essentials, where available, or in writing to the address listed in your Provider Manual. To submit via Availity Essentials: After logging in, locate the claim you want to dispute using Claim Status from the Claims & Payments menu. If available, select Dispute Claim to initiate the dispute. From the Claims & Payments menu select Appeals to locate the initiated dispute, upload supporting documentation, complete the wizard and submit. If the option to dispute a claim is unavailable, submit your request in writing to the address listed in the Provider Manual. Please provide this information to your billing staff and/or office managers, and if you have any questions, contact your Provider Relationship Management associate. Please note: This change does not apply to appeals regarding a clinical decision denial, such as a utilization management authorization or a Claim that has been denied as not medically necessary or experimental/investigational. For more information on Clinical/Medical Necessity Appeals, refer to the Clinical Appeals section within the Provider Manual. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. MULTI-BCBS-CM-015799-22-CPN15794 Administrative | Anthem Blue Cross and Blue Shield | Commercial | March 31, 2023 Notice of material change/amendment to contract Genetic testing CPT code list update for Carelon Medical Benefits Management (formerly AIM Specialty Health)Effective for dates of service on and after July 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management (formerly AIM Specialty Health®).* CPT® code | Description | 81309 | PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (for example, ectal and breast cancer) gene analysis, targeted sequence analysis (for example, exons 7, 9, 20) | 81335 | TPMT (thiopurine S-methyltransferase) (for example, drug metabolism), gene analysis, common variants (for example, *2, *3) | 81405 | Molecular pathology procedure, Level 6 (for example, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis) ABCD1 (ATP-binding cassette, sub-family D ALD, member 1) (for example, adrenoleukodystrophy), etc. | 81406 | Molecular pathology procedure, Level 7 (for example, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons) ACADVL (acyl-CoA dehydrogenase, very long chain) (for example, very long chain acyl-coenzyme A dehydrogenase deficiency), etc. | 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP-L3 and oncoprotein des-gamma-carboxy-prothrombin (DCP), algorithm reported as normal or abnormal result | 0336U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, blood or saliva, identification and categorization of genetic variants, each comparator genome (for example, parent) | 0339U | Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first-void urine following digital rectal examination, algorithm reported as probability of high-grade cancer | 0340U | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next-generation sequencing of the patient's tumor and germline DNA, reported as absence or presence of MRD, with disease-burden correlation, if appropriate | 0343U | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as molecular evidence of no-, low-, intermediate- or high-risk of prostate cancer | 0345U | Psychiatry (for example, depression, anxiety, attention deficit hyperactivity disorder ADHD), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 | 0347U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes | 0348U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes | 0349U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and impacted gene-drug interactions | 0350U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes |
As a reminder, ordering and servicing providers may submit prior authorization requests for Commercial consumers to Carelon in one of several ways: - Access Carelon’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.
If you have questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-017765-23-CPN17413 ATTACHMENTS (available on web): CG-Gene-11.pdf (pdf - 9.55mb) CG-Gene-13.pdf (pdf - 22.33mb) GENE.00009.pdf (pdf - 11.68mb) GENE.00010.pdf (pdf - 4.46mb) GENE.00049.pdf (pdf - 6.97mb) GENE.00052.pdf (pdf - 17.7mb) GENE.00059.pdf (pdf - 1.96mb) Anthem Blue Cross and Blue Shield updates the provider manuals annually so that our care provider partners have the current information they need to work with us. The provider manual serves as a reference document and is reviewed internally each year to reflect changes to our processes and policies. The provider manual incorporates information for both professional and hospital/facility providers. The next update will be available on the website on April 1, 2023, and will become effective on July 1, 2023. To view the updated manual, please visit anthem.com. Select Providers, then Policies, Guidelines & Manuals. Select your state, scroll to Provider Manual, and select Download the Manual to view and/or download the provider manual as well as BlueCard and Medicare Advantage manuals. Archived copies of the professional and hospital/facility manual will remain available at the same location. MULTI-BCBS-CM-020706-23-CPN20586 Administrative | Anthem Blue Cross and Blue Shield | Commercial | March 31, 2023 Notice of material change/amendment to contract Expansion of Carelon Medical Benefits Management, Inc. cardiology, genetic testing, and radiology programs effective August 1, 2023Effective August 1, 2023, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross and Blue Shield (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 cardiology, genetic testing, and radiology 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 July 17, 2023, for dates of service August 1, 2023, and after. Members included in the new program All fully insured (FI), self-funded (ASO) 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 August 1, 2023. Members of the following products are excluded: Medicare Advantage, Medicaid, original Medicare, Medicare supplement, Medicare Advantage Group Retiree Solutions, Federal Employee Program® (FEP®). Pre-service review requirements For procedures that are scheduled to begin on or after August 1, 2023, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following nonemergency modalities. Please refer to the program microsite resource pages for complete code lists. Program | Services | Clinical guidelines | Cardiology | - Cardiac Resynchronization Therapy (Pacemakers/Defibrillator/Electrode 1)
- Peripheral Revascularization
| - CG-SURG-49
- CG-SURG-63
- CG-SURG-97
- MCG: W0099
| Genetic testing | - Whole Genome sequencing
- Gene Expression Profiling for Idiopathic Pulmonary Fibrosis
- Genetic Testing to Confirm the Identify of Laboratory Specimens
- Cell-free DNA testing to aid in monitoring of kidney transplants.
- Laboratory testing to aid in diagnosis of heart transplant rejection.
| - GENE.00052
- GENE.00057
- GENE.00041
- LAB.00038
- TRANS.00025
| Radiology | | - Chest Imaging (to be announced in an upcoming newsletter)
- Oncologic Imaging (to be announced in an upcoming newsletter)
|
To determine if prior authorization is needed for a member on or after August 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. (Note: Providers cannot use the Interactive Care Reviewer (ICR) tool on Availity Essentials* to pre-certify an outpatient procedure or any 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 ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to Carelon Medical Benefits Management to register. For more information Visit the resources below to help your practice get started with the radiology, cardiology, and genetic testing programs. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQ. You can also reach out to your local Network Relations representative. Resources: Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed. Submit updates and corrections to your online directory information by using our online Provider Maintenance Form. Once you submit the form, we will send you an email acknowledging receipt of your request. Update options include: - Add/change an address location
- Name change
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information helps us ensure your online provider directory information is current.
MULTI-BCBS-CM-019844-23-CPN19832 On March 26, 2023, Carelon Medical Benefits Management Inc. (formerly AIM Specialty Health)* released operational enhancements to the ProviderPortalSM for the Medical Oncology Program for Anthem Blue Cross and Blue Shield. These enhancements are geared towards creating an easier intake process for users. You may notice the clinical intake screens look and function differently. A few updates will include: - Improved look and feel of the case entry screens.
- Removal of unnecessary biomarker questions for specific clinical scenarios.
- Revised drug dosing screens for easier input of cycle ranges and days of administration.
Resources, training, and support To familiarize yourself with the enhanced medical oncology authorization request process, Carelon will be hosting a series of provider training sessions. Please register to receive a unique meeting invite. For more information Carelon has a designated email address for provider questions about the ProviderPortal and case entry process; please use MedicalOncologySolution@carelon.com. All member eligibility or claims questions should be directed to your health plan network representative. Thank you for your continued support of this program.
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-020077-23-CPN19726 Make sure your correspondence includes one of these elements The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is: - We’ll receive the documents needed faster than through the mail.
- Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
- Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
- More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.
However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays: - Valid claim number and valid member ID
or
- Valid member ID with prefix and correct dates of service
or
- Valid member ID with prefix and billed charges
For a clinical appeal, ensure these elements are included: - Valid claim number and valid member ID
or
- Valid member ID with prefix and correct dates of service
or
- Valid member ID with prefix and billed charges
or
- Member name, member date of birth, and correct dates of service
or
- Member name, member date of birth, and authorization or reference number
This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission. The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission. To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation. For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal. If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation. For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow. * Availity, LLC is an independent company providing administrative support services on behalf of health plan. MULTI-BCBS-CM-021194-23-CPN20715 To help inform referrals and placements, we are asking all skilled nursing facilities (SNFs) to complete the following survey, which will allow us to have the most up-to-date information about your facility and allow us to provide the best possible service to you and to our members — your patients. Please visit https://chkmkt.com/SNFCapabilitySurvey to complete the survey. It should only take about 10 minutes of your time. MEBCBS-CM-013187-22-CPN11464 Reimbursement Policies | Anthem Blue Cross and Blue Shield | Commercial | March 31, 2023 Notice of material change/amendment to contract Notification Regarding Reimbursement Changes to COVID-19 Vaccine AdministrationBeginning with dates of service on or after July 1, 2023 reimbursement for COVID-19 vaccine administration codes will be reduced. New COVID-19 vaccine administration codes were implemented and reimbursed at rates to meet the needs of providers during the Covid Public Health Emergency (PHE). Reimbursement will now be revised to Anthem Blue Cross and Blue Shield (Anthem)’s standard reimbursement methodology to align with other vaccine administration rates (for example, flu) for the codes listed below. If you have any questions regarding this notice, use live Chat on Availity Essentials, available during normal business hours, or contact Provider Services by phone. To Chat, log onto Availity.com and select Anthem from the Payer Spaces drop-down menu. Then, select Chat with Payer to complete the pre-chat form and to start your chat. CPT® Code or HCPCS Code | CPT or HCPCS Short Descriptor | Labeler Name | Vaccine/Procedure Name | 0001A | ADM SARSCOV2 30MCG/0.3ML 1ST | Pfizer | Pfizer-BioNTech Covid-19 Vaccine Administration – First Dose | 0002A | ADM SARSCOV2 30MCG/0.3ML 2ND | Pfizer | Pfizer-BioNTech Covid-19 Vaccine Administration – Second Dose | 0003A | ADM SARSCOV2 30MCG/0.3ML 3RD | Pfizer | Pfizer-BioNTech Covid-19 Vaccine Administration – Third Dose | 0004A | ADM SARSCOV2 30MCG/0.3ML BST | Pfizer | Pfizer-BioNTech Covid-19 Vaccine Administration – Booster | 0011A | ADM SARSCOV2 100MCG/0.5ML1ST | Moderna | Moderna Covid-19 Vaccine Administration – First Dose | 0012A | ADM SARSCOV2 100MCG/0.5ML2ND | Moderna | Moderna Covid-19 Vaccine Administration – Second Dose | 0013A | ADM SARSCOV2 100MCG/0.5ML3RD | Moderna | Moderna Covid-19 Vaccine Administration – Third Dose | 0021A | ADM SARSCOV2 5X10^10VP/.5ML 1 | AstraZeneca | AstraZeneca Covid-19 Vaccine Administration – First Dose | 0022A | ADM SARSCOV2 5X10^10VP/.5ML 2 | AstraZeneca | AstraZeneca Covid-19 Vaccine Administration – Second Dose | 0031A | ADM SARSCOV2 VAC AD26 .5ML | Janssen | Janssen Covid-19 Vaccine Administration - First Dose | 0034A | ADM SARSCOV2 VAC AD26 .5ML B | Janssen | Janssen Covid-19 Vaccine Administration - Booster | 0041A | ADM SARSCOV2 5MCG/0.5ML 1ST | Novavax | Novavax Covid-19 Vaccine Administration – First Dose | 0042A | ADM SARSCOV2 5MCG/0.5ML 2ND | Novavax | Novavax Covid-19 Vaccine Administration – Second Dose | 0044A | ADM SARSCOV2 5MCG/0.5ML BST | Novavax | Novavax Covid-19 Vaccine, Adjuvanted Administration - Booster | 0051A | ADM SARSCV2 30MCG TRS-SUCR 1 | Pfizer | Pfizer-BioNTech Covid-19 Vaccine (Ready to Use) Administration - First dose | 0052A | ADM SARSCV2 30MCG TRS-SUCR 2 | Pfizer | Pfizer-BioNTech Covid-19 Vaccine (Ready to Use) Administration - Second dose | 0053A | ADM SARSCV2 30MCG TRS-SUCR 3 | Pfizer | Pfizer-BioNTech Covid-19 Vaccine (Ready to Use) Administration - Third dose | 0054A | ADM SARSCV2 30MCG TRS-SUCR B | Pfizer | Pfizer-BioNTech Covid-19 Vaccine (Ready to Use) Administration - Booster | 0064A | ADM SARSCOV2 50MCG/0.25MLBST | Moderna | Moderna Covid-19 Vaccine (Low Dose) Administration - Booster | 0071A | ADM SARSCV2 10MCG TRS-SUCR 1 | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine - Administration - First dose | 0072A | ADM SARSCV2 10MCG TRS-SUCR 2 | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine - Administration - Second dose | 0073A | ADM SARSCV2 10MCG TRS-SUCR 3 | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) - Administration - Third dose | 0074A | ADM SARSCV2 10MCG TRS-SUCR B | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - Booster | 0081A | ADM SARSCOV2 3MCG TRS-SUCR 1 | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - First dose | 0082A | ADM SARSCOV2 3MCG TRS-SUCR 2 | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Second dose | 0083A | ADM SARSCOV2 3MCG TRS-SUCR 3 | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Third dose | 0091A | ADM SARSCOV2 50 MCG/.5 ML1ST | Moderna | Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - First dose | 0092A | ADM SARSCOV2 50 MCG/.5 ML2ND | Moderna | Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Second dose | 0093A | ADM SARSCOV2 50 MCG/.5 ML3RD | Moderna | Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Third dose | 0094A | ADM SARSCOV2 50MCG/0.5 MLBST | Moderna | Moderna Covid-19 Vaccine (Aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML Administration - Booster | 0111A | ADM SARSCOV2 25MCG/0.25ML1ST | Moderna | Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - First dose | 0112A | ADM SARSCOV2 25MCG/0.25ML2ND | Moderna | Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Second dose | 0113A | ADM SARSCOV2 25MCG/0.25ML3RD | Moderna | Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Third dose | 0124A | ADM SARSCV2 BVL 30MCG/.3ML B | Pfizer | Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Gray Cap) Administration – Booster Dose | 0134A | ADM SARSCV2 BVL 50MCG/.5ML B | Moderna | Moderna COVID-19 Vaccine, Bivalent (Aged 12 years and older) (Dark Blue Cap with gray border) Administration – Booster Dose [6] | 0144A | ADM SARSCV2 BVL 25MCG/.25ML B | Moderna | Moderna COVID-19 Vaccine, Bivalent (Aged 6 years through 11 years) (Dark Blue Cap with gray border) Administration – Booster Dose | 0154A | ADM SARSCV2 BVL 10MCG/.2ML B | Pfizer | Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 5 years through 11 years) (Orange Cap) Administration – Booster Dose | 0164A | ADM SRSCV2 BVL 10MCG/0.2ML B | Moderna | Moderna COVID-19 Vaccine, Bivalent (Aged 6 months through 5 years) (Dark Pink Cap and label with a yellow box) Administration – Booster Dose | 0173A | ADM SARSCV2 BVL 3MCG/0.2ML 3 | Pfizer | Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Third dose | M0201 | Covid-19 vaccine home admin | Home vaccine admin | Covid-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient's home |
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CM-021025-23 Reimbursement Policies | Anthem Blue Cross and Blue Shield | Commercial | March 31, 2023 Notice of material change/amendment to contract Reimbursement policy update: Bundled Services and Supplies - ProfessionalEffective July 1, 2023, Anthem Blue Cross and Blue Shield will update the Bundled Services and Supplies — Professional reimbursement policy to include six Centers for Medicare & Medicaid Services (CMS) immunization counseling codes. These codes will be added to the policy under Section 1: Services and supplies not eligible for separate reimbursement.
The following codes are not eligible for reimbursement when reported with another service or reported as a stand-alone service: - G0310 — Immunization counseling by a physician or other qualified healthcare professional when the vaccine(s) is not administered on the same date of service, 5 to 15 minutes time (this code is used for Medicaid billing purposes)
- G0311 — Immunization counseling by a physician or other qualified healthcare professional when the vaccine(s) is not administered on the same date of service, 16 to 30 minutes time (this code is used for Medicaid billing purposes)
- G0312 — Immunization counseling by a physician or other qualified healthcare professional when the vaccine(s) is not administered on the same date of service for ages under 21, 5 to 15 minutes time (this code is used for Medicaid billing purposes)
- G0313 — Immunization counseling by a physician or other qualified healthcare professional when the vaccine(s) is not administered on the same date of service for ages under 21, 16 to 30 minutes time (this code is used for Medicaid billing purposes)
- G0314 — Immunization counseling by a physician or other qualified healthcare professional for COVID-19, ages under 21, 16 to 30 minutes time (this code is used for the Medicaid early and periodic screening, diagnostic, and treatment [EPSDT] benefit)
- G0315 — Immunization counseling by a physician or other qualified healthcare professional for COVID-19, ages under 21, 5 to 15 minutes time (this code is used for the Medicaid EPSDT benefit)
For specific policy details, visit the Anthem Blue Cross and Blue Shield reimbursement policy page: MULTI-BCBS-CM-018573-23-CPN18573 ATTACHMENTS (available on web): Bundled Services.pdf (pdf - 0.34mb) Effective April 1, 2023, Anthem Blue Cross and Blue Shield will update the documentation and reporting guidelines for Evaluation and Management Services — Professional reimbursement policy to align with CMS guidance for documenting evaluation and management (E/M) services and determining E/M service level. This update includes CMS’ adoption of the American Medical Association (AMA) Current Procedural Terminology® (CPT) 2023 code changes for Other E/M Services (except for prolonged services), as detailed below. Adoption of 2023 code changes As of January 1, 2023, CMS adopted the revised AMA CPT codes for Other E/M Services (except for prolonged services). These code changes include: - Allowing total time to be used for determining service level for timed visits.
- Requiring a medically appropriate history and/or exam, rather than using history and exam to determine visit level.
- Merger of hospital inpatient and observation visits code sets.
- Merger of domiciliary, rest home, or custodial care and home visits code sets.
- New descriptor times (where relevant).
- Revised CPT E/M guidelines for levels of medical decision making (MDM).
Other E/M Services include: - Inpatient and observation visits.
- Emergency department visits.
- Nursing facility visits.
- Domiciliary or rest home visits.
- Home visits.
- Cognitive impairment assessment.
Documentation requirements for using time to determine E/M service This reimbursement policy is also being updated to clarify documentation requirements when evaluating an E/M service based on total time. While the use of time for determining E/M service is intended to ease the reporting burden on providers, documentation must still be sufficient to establish medical necessity and exact time. Documentation should describe the activities performed during the period of E/M service and the total time must be specifically stated, rather than stated as an approximate range. If the documentation requirements are not met for the use of time in establishing the level of service, then the claim will be evaluated using MDM criteria. Reference Medicare Physician Fee Schedule Final Rule Summary: CY 2023. MLN Matters Number: MM12982. https://www.cms.gov/files/document/mm12982-medicare-physician-fee-schedule-final-rule-summary-cy-2023.pdf For specific policy details, visit the reimbursement policy page at anthem.com.
MULTI-BCBS-CM-021000-23-CPN20623 Q: What is Pay Doctor Bill? A: Anthem Blue Cross and Blue Shield (Anthem) contracted with a vendor to deliver options for consumers to view their claims and pay their out-of-pocket responsibility to doctors from the Sydney Health mobile app or from https://www.anthem.com/provider. This is not related to the payment of health insurance premiums. Q: What is happening with the Pay Doctor Bill option? A: Anthem will stop offering this option to consumers effective March 31, 2023. Q: Why is Pay Doctor Bill going away? A: This was not a good overall consumer (and provider) experience. We are always committed to keeping consumers at the center of everything we do and will be exploring other options. Q: What other options will consumers have to pay doctor bills? A: Even though this option will no longer be available, consumers still have other ways of paying doctors: - Through a Health Savings Account (HSA) or Flexible Spending Account (FSA) if they have this type of account
- Through the consumer’s bank’s bill pay feature on a mobile app or website
- Directly through the doctor’s secure payment website or at the doctor’s office with a debit or credit card
Q: How will consumers be notified that the feature is going away? A: A month prior to the Pay Doctor Bill option being removed from the Sydney Health mobile app and the Anthem website, we will notify consumers within these applications. Q: How will providers be notified that the feature is going away? A: Providers will be notified about these changes in the March 1, 2023, provider newsletter. Q: Who is the vendor that provides consumers with access to this provider payment option? A: InstaMed* is the name of the vendor. * InstaMed is an independent company providing consumers with access to provider payment options on behalf of the health plan. MEBCBS-CM-015136-22-CPN15132 If your practice is looking for ways to improve your vaccination strategy and help protect the health of your patients through vaccines, we can help. Let’s Vaccinate provides ready-to-use resources and strategies to help your care team increase vaccination rates. Let’s Vaccinate https://www.letsvaccinate.org/ was redesigned to help you increase vaccination rates among your patients through ready-to-use resources that focus on the two main strategies that most directly impact your vaccination rates: one) optimizing your office workflows and two) enhancing patient engagement. Optimizing office workflows Let’s Vaccinate can help your care team improve office workflows during and after office visits, as well as for proactive patient outreach. The website includes resources and strategies for: - Leveraging electronic health record systems (EHR) to help with vaccine assessments, reminders, and documentation.
- Customizing outreach to influence your patients’ decisions to get vaccinated.
- Implementing recommended office workflows to help ensure that patients are getting the vaccines they need.
Enhancing patient engagement Let’s Vaccinate can help your care team improve patient communication by allowing them to better understand the many social, geographic, political, economic, and environmental factors that create challenges to vaccination access, and address patients’ feelings about vaccine safety. The website includes resources and strategies for: - Making strong recommendations.
- Addressing vaccine hesitancy and disparities.
- Using effective patient education handouts and toolkits.
Keeping your patients healthy and safe requires the collaboration of your entire care team. The power is in your hands. So, let’s get started! Let’s Vaccinate is a collaboration of health plans, HealthyWomen, and Pfizer Inc. * Let’s Vaccinate, in collaboration with HealthyWomen and Pfizer, Inc., is an independent initiative providing vaccine information on behalf of the health plan. MULTI-BCBS-CM-019840-23-CPN19797 Reveleer* is the contracted vendor to gather consumer 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. Reveleer 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 business days of the record requests. If you have any questions, you can reach a Reveleer representative by calling 855-454-6182 or contact Pragna Halder with Blue Cross and Blue Shield Federal Employee Program at 202-942-1186. * Reveleer is an independent company providing medical record review services on behalf of the health plan. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). MULTI-BCBS-CM-019354-23 The Federal Employee Program® (FEP) rolled out a Quality Reimbursement Program for providers in April 2022, where coding for CPT® category II codes for A1c results, blood pressure readings, and the first prenatal visit are reimbursed at $10 per code. Over the past year, the program has been a success in improving HEDIS® scores and reducing administrative burden. Effective May 12, 2023, the FEP Quality Reimbursement Program for PPO providers will undergo the revisions listed below. Revisions to CPT Category II code requirements for $10 reimbursement: - Only professional CMS-1500 billing providers
- Only these six places of service codes are applicable:
- 02: 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 Category II code
Submitting the claim: - Submit the CPT category II code in field 24 of the CMS-1500 and a charge of $10.
- Use the applicable CPT category II code, place of service code, and diagnosis code according to the information below.
Blood pressure — systolic and diastolic readings: - Reimbursable ICD-10-CM diagnosis codes: I10, I11.9, I12.9, I13.10, I15, I15.1, I15.8, I15.9, I16.0, I16.1, I16.9
- CPT category II codes:
- 3074F: Most recent systolic blood pressure less than 130 mm Hg
- 3075F: Most recent systolic blood pressure 130 to 139 mm Hg
- 3077F: Most recent systolic blood pressure greater than or equal to 140 mm Hg
- 3078F: Most recent diastolic blood pressure less than 80 mm Hg
- 3079F: Most recent diastolic blood pressure 80 to 89 mm Hg
- 3080F: Most recent diastolic blood pressure greater than or equal to 90 mm Hg
Hemoglobin A1c: - Reimbursable ICD-10-CM diagnosis codes: E10.8, E10.9, E11.8, E11.9
- CPT category II codes:
- 3044F: Most recent hemoglobin A1c (HbA1c) level less than 7.0%
- 3046F: Most recent hemoglobin A1c (HbA1c) level greater than 9.0%
- 3051F: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0%
- 3052F: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%
First prenatal visit — The first prenatal visit date of service must be on the claim (field 24A, CMS-1500) with the appropriate code: - Reimbursable ICD-10-CM diagnosis codes: maternity related diagnosis code
- CPT category II codes:
- 0500F: Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit, and in a separate field, the date of the last menstrual period [LMP]) (Prenatal)
- 0501F: Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period [LMP] (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit) (Prenatal)
For additional information about the FEP Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.
Visit the Drug Lists page on our provider website at https://www.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 www.fepblue.org > Pharmacy Benefits. To help inform referrals and placements, we are asking all skilled nursing facilities (SNFs) to complete the following survey, which will allow us to have the most up-to-date information about your facility and allow us to provide the best possible service to you and to our members — your patients. Please visit https://chkmkt.com/SNFCapabilitySurvey to complete the survey. It should only take about 10 minutes of your time. MEAMH-CR-013186-22-CPN11464 Medicare Advantage allows coverage of online evaluation and management services for an established patient when all requirements have been met. The communication between patient and doctor is a cumulative of seven days and with at least the minimum of the minutes for the CPT® code being billed. Any services amounting to less than five minutes would not be appropriate to bill as an e-visit.
CPT code | Description | 99421 | Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 5 to 10 minutes | 99422 | Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11 to 20 minutes | 99423 | Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes | 98970 | Qualified nonphysician healthcare professional online digital assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 5 to 10 minutes | 98971 | Qualified nonphysician healthcare professional online digital assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 11 to 20 minutes | 98972 | Qualified nonphysician healthcare professional online digital assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes |
Here is a communication by CMS to help with further questions: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.
MEAMH-CR-016638-23-CPN16365 |