We continue to make it easier and more convenient to become a participating provider. The Digital Provider Enrollment Application has been designed to speed up the enrollment process, allow providers to submit data at one time, and obtain real-time updates on the status of an application.

Access to the application is available through Availity, Anthem’s secure web-based provider portal. New and current Availity users should ensure their user ID has the correct access. Please ensure that you have been assigned access to Provider Enrollment.

Digital Provider Enrollment offers many benefits:

• Now, non-credentialed provider types who do not have a CAQH ID can also use the digital enrollment process
• Continues to support enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with Anthem.
• New individual providers or groups can request a contract.
• Existing groups can add providers to their existing contract.
• Providers can check the status of an application in real-time using the enrollment dashboard.

To use the new Digital Enrollment application, please ensure your provider data on CAQH is current and in a complete or re-attested status, then log into Availity and use the following navigation: Choose your state > Payer Spaces > Provider Enrollment.

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Anthem is transitioning to Availity Authorization

You may already be familiar with the Availity Authorization App because millions of providers are already using it to submit prior authorizations for other payers. We are eager to make it available to providers to submit prior authorizations for Anthem members, too. In September 2021, you can begin using the same authorization app you use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Anthem.

Current prior authorization app Interactive Care Reviewer (ICR) is still available

If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We’ve developed a pathway for you to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization App.

Innovation in progress

While we grow the Availity Authorization App to provide you with Anthem-specific information, we’ve provided access to ICR for:

• Appeals
• Behavioral health authorizations
• FEP authorizations
• Medical specialty Rx

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

Training is coming soon

If you aren’t already familiar with the Availity Authorization App, live training and recorded webinars will be available in September and announced in the next issue of Provider News.

Give it a try!

Accessing the Availity Authorization App is easy. Just log onto Availity.com and the Authorization icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorization and Referral.

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We’re making it even easier for you to schedule online appointments through the Appointment Scheduler App on Availity. The Appointment Scheduler App gives you secure access to new appointment requests. You’ll also receive digital access to the member’s ID number, contact information and any special health information.

Appointment Scheduler App features include:

• Manage appointment requests
• Configure appointment availability
• Notifications for new visit requests on your Availity dashboard
• Members are automatically notified by text or email when appointments are confirmed

Administrators, administrator assistants and users with the role of ‘office staff’ will have access to the Appointment Scheduler App.

To access Appointment Scheduler, log onto Availity.com and select Anthem from Payer Spaces. The Appointment Scheduler App will be located in your Applications menu. To learn more about the new App, go to the Custom Learning Center in Availity and keyword search Appointment Scheduler.

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Beginning with dates of service on or after November 1, 2021, Anthem’s current Telehealth policy will be renamed Virtual Visits.  We allow reimbursement for professional and facility Virtual Visits when interactive services occur between the member and the provider, when they are not in the same location, unless provider, state, or federal contracts and/or mandates indicate otherwise. Reimbursement is allowed for professional and facility Virtual Visits rendered at the distant site via live audio visual services and for Remote Patient Monitoring. Services reported by a professional provider with a place of service Telehealth (02) will be eligible for non-office place of service reimbursement. In addition, facility Virtual Visits will be allowed for the originating site fee. The Related Coding section details the modifiers allowed for reimbursement.

For more information about this policy, visit the Reimbursement Policies page at anthem.com. 

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Beginning with dates of service on or after November 1, 2021, we will update the Related Coding section to indicate no modifier override for the neurostimulator device when billed with the surgical code for the implantation of the neurostimulator device.

The following code pairs have been added to the Related Coding Section:

• L8680 when reported with 63655
• L8679 when reported with 63650
• L8679 when reported with 63655
• L8687 when reported with 63650
• L8687 when reported with 63655

For more information about this policy, visit the Reimbursement Policies page at anthem.com. 

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In our May issue of Provider News, we announced a threshold increase for the itemized bill requirement for outpatient facility claims. This requirement will remain; however, effective August 1, 2021, we will remove the threshold amount from the policy language for outpatient facility claims and inpatient stay claims.

For more information about this policy, visit the Reimbursement Policies page at anthem.com.  

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Effective November 1, 2021, in order to help ensure our member’s security, the Blue Cross and Blue Shield Federal Employee Program (FEP®) will be decommissioning the Utilization Management (UM) email address for processing eReviews, FEPE-Reviews@anthem.com. As an alternative, FEP offers providers a secure online portal, Interactive Care Reviewer (ICR).

About the ICR portal

ICR is Anthem’s innovative UM portal that allows providers, in addition to phone or fax, to submit prior authorization requests and to provide clinical documentation (including imaging) to support initial and continued stay reviews. This enables prior authorization requests and clinical information to be transmitted directly to UM staff.

Key features of ICR

• No cost electronic UM solution
• Instant access from any location at any time
• Create a UM preauthorization case and instantly submit it for review
• Attach clinical documents for review – no faxing required
• Check status of any case regardless of the method used to originally submit request
• Complete record of submissions and dispositions – all in one place
• Bi-directional communication

To submit prior authorization service requests electronically, register for use of Interactive Care Reviewer (ICR) prior to November 1, 2021 on the Availity portal.

For more information on Anthem ICR, including training resources: https://www.anthem.com/provider/prior-authorization/interactive-care-reviewer/

Register for ICR via the Availity portal: https://www.availity.com/provider-portal-registration

Need help registering? View this video: How to Access Availity and Register

As a reminder, in addition to using ICR on the Availity portal, you can submit authorizations, to FEP UM by phone or fax: 

• FEP UM precertification toll free: 800-860-2156
• FEP UM precertification fax: 800-732-8318
• FEP UM Advance Benefit determination fax: 877-606-3807

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For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions and other requirements, restrictions or limitations that apply to certain drugs, visit anthem.com/pharmacyinformation. The commercial and marketplace drug lists are reviewed and updates are posted to the website quarterly (the first of the month for January, April, July and October).

• To locate the commercial drug list, select ‘Click here to access your drug list’.
• To locate the Marketplace Select Formulary and pharmacy information, scroll down to ‘Select Drug Lists’, then select the applicable state’s drug list link.

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

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Prior authorization updates

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Please note, 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.

Visit our website to access the clinical criteria information.  

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use will be managed by AIM Specialty Health® (AIM).

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

**Oncology use is managed by AIM.

Quantity limit updates

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

Please note, 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.

Visit our website to access the clinical criteria information.  

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

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Effective with dates of service on and after October 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem will update our drug lists that support commercial health plans.

Updates include changes to drug tiers and the removal of medications from the formulary.

Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.

To help ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.

View a summary of changes in the attached PDF. 

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We are committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

Effective with dates of service on or after August 1, 2021, providers treating members covered by Anthem commercial plans may be asked to consider voluntarily using adjusted body weight (AdjBW) dosing compared to actual body weight (ABW) dosing for immune globulin medications. The dose change using AdjBW will only be made if the member’s actual body weight is more than 20% of the ideal body weight (IBW).

Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization. 

Reviews for the immune globulin medications will continue to be administered by IngenioRx® as these will specifically target specialty non-oncology indications.

As part of the prior authorization process, providers may be asked the following questions:

• Whether the suggested use of AdjBW and change in dose is clinically acceptable
• Clinical reasoning if the dose change (using AdjBW) is not appropriate

Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

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We are committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

Effective with dates of service on or after August 1, 2021, providers treating members covered by Anthem Commercial plans may be asked to consider voluntarily reducing the requested dose to avoid vial wastage for select non-oncology specialty medications. The dose reduction suggestion will only be made if the originally requested dose is within 10% of the nearest whole vial.

Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization. 

Reviews for these specialty drugs will continue to be administered by IngenioRx_®.

As part of the prior authorization process, providers may be asked the following questions:

• Whether the suggested dose reduction is clinically acceptable
• Clinical reasoning if the dose reduction is not appropriate

Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

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Providers treating members covered by Anthem plans will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications (see list below). Reviews for these oncology drugs will continue to be administered by AIM Specialty Health® (AIM).

As part of the online prior authorization process, providers will be asked about the dosage of the medication being requested in pop-up questions:

• Whether or not the recommended dose reduction is acceptable
• If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning.

For prior authorization requests made outside of the online AIM Provider Portal (i.e. via phone or fax) the same questions will be asked by the registered nurse or medical director reviewing the request.  Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.

The dose reduction questions will appear only if the originally requested dose is within 10 percent of the nearest whole vial. This threshold is based on the current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) it is appropriate to consider dose rounding within 10 percent. View the HOPA recommendations here.

The voluntary dose reduction program only applies to the specific oncology drugs listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

Note: In some plans “dose reduction to nearest whole vial” or another term “waste reduction” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “dose reduction to nearest whole vial” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “dose reduction (to nearest whole vial).”

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

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