 Provider News MaineDecember 2021 Anthem Maine Provider News Contents Administrative | Anthem Blue Cross and Blue Shield | Commercial | December 1, 2021 Coordination of care
As we announced in the October edition of Provider News, Anthem is working to comply with the requirements of the Consolidated Appropriations Act, or CAA.
Improving the accuracy of provider directory information
As part of the CAA, soon providers will be asked to verify their online provider directory information on a regular basis to help ensure Anthem members can locate the most current information for in-network providers and facilities. It is important that you keep your information up to date. Here’s what you can do now:
- Review your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To help ensure we have your most current and accurate information, please take a moment to access Find Care. Go to anthem.com, select Providers, then under Provider Overview, choose Find Care.
- Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
Consolidated Appropriations Act implementation
The CAA does not preempt state law requirements. This means that the CAA applies in addition to any state l aw requirements of providers to update their provider directory information.
On August 20, 2021, the Tri-Agencies (Departments of Labor, Health and Human Services and the Treasury) announced that regulations to implement the provider directory requirements would be issued on or after January 1, 2022. Health plans are expected to implement the provider directory requirements based on a good faith, reasonable interpretation of the requirements by January 1, 2022, with a primary focus on ensuring that members who rely on provider directory information that inaccurately depicts a provider’s network status are only liable for in-network cost sharing amounts. Anthem is moving forward with compliance of this good faith, reasonable interpretation of the requirements while awaiting additional regulatory guidance.
Watch for upcoming editions of Provider News in 2022 for updates on our ongoing efforts to comply with the CAA requirements.
For more than a decade, Blue Precision – Anthem’s physician transparency program – has recognized specialists for meeting or exceeding established quality and cost effectiveness measures. Thank you to all those physicians participating in our networks and for the care you provide to our members.
As we announced in the July 2021 edition of Provider News, we have made the business decision to retire our Blue Precision program effective December 31, 2021. Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.
Going forward, we will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare.
To help ensure accurate reimbursement, it is important that the provider types outlined below report the following taxonomy codes to Anthem when providing services in the referenced medical capacity.
Please reference the NUCC guidelines for further CMS-1500 claim reporting guidance.
Advanced practice registered nurses/mid-wives
|
APRN
|
CRNA
|
MID-WIFE
|
Surgical first assist
|
163WR0006X
|
|
163WR0006X
|
Behavioral health
|
363LP0808X
|
|
|
Anesthesia
|
|
367500000X
|
|
Physician assistants
Surgical first assist
|
363AS0400X
|
Behavioral health
|
363A00000X
|
Primary care (pcp)
|
363AM0700X
|
Specialist
|
363AM0700X
|
Behavioral health facilities
If you are a behavioral health facility that bills Anthem at the organizational level on the CMS 1500, report the following taxonomy codes in the Billing Taxonomy field on the CMS-1500 (paper - field 33b, electronic - Loop 2000A/Segment PRV - field 39)
Adult psychiatrist (MD/DO)
|
2084P0800X
|
Child psychiatrist (MD/DO)
|
2084P0804X
|
Psychologist (PhD)
|
103TC0700X
|
Advanced practice nurse (APRN)
|
363LP0808X
|
Masters (MDIV, LPC, LCSW, LCPC, RNCS, etc.)
|
193200000X
|
As a reminder, we will upgrade our claim editing software for professional services monthly throughout 2022, with most updates occurring quarterly. These upgrades may apply to same provider, provider group (tax identification number). They may also apply across providers and across claim types (professional/facility) and include, but are not limited to:
- addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits such as:
- ICD-10 laterality and Excludes1 notes
- Add-on procedures (indicated by + sign)
- Code book parenthetical statements and other directives about appropriate code use (e.g. “separate procedure”, “do not report”, “list separately in addition to”, etc...)
- updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
- updates to incidental, mutually exclusive, and unbundled (rebundle) edits
- updates to assistant and co-surgeon eligibility in accordance with the policy
- updates to edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
As a reminder, we will continue to upgrade our claim editing software for outpatient facility services monthly throughout 2022, with most updates occurring quarterly. These upgrades will include, but are not limited to:
- Addition of new and revised codes (for example CPT, HCPCS, ICD-10, modifiers, and revenue codes) and their associated edits
- Updates related to the appropriate use of various code combinations, which can include, but are not limited to:
- Procedure code to revenue code
- HCPCS to revenue code
- Type of bill to procedure code
- Type of bill to HCPCS code
- Procedure code to modifier
- HCPCS to modifier
- Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
- Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC)
The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem Plans assessed fell short of the expectation of having a live person or a directive in place after hours.
The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:
- inaccurate provider information in Anthem’s demographic database to allow assessment of the after-hours messaging
- no voicemail or messaging at all
- voicemail not reflecting the practitioner’s name, and/or
- calls being auto forwarded with no identification, no voicemail or messaging
To help both your patients’ and Anthem’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.
What does this mean for our members and your patients? The annual member experience survey of Anthem enrollees indicated of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these three steps:
- Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
- Be sure to turn on the messaging mechanism when you leave the office.
- Be sure you are using the acceptable messaging for compliance with your contract.
To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:
Emergency situations
Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER.
Urgent situations
Compliant responses for urgent needs after hours:
- Live person, via a service or hospital, advises practitioner or on call practitioner is available and connects.
- Live person or recording directs caller/patient to Urgent Care, ER or call 911.
Non-compliant responses for urgent needs after hours:
- No provision for after-hours accessibility.
- Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. (Not a direct connection to their practitioner.)
Is your practice compliant?
Talking to a teenager about chlamydia can be difficult. But, if untreated, this typical teenager could develop pelvic inflammatory disease (PID) or worse, infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. For a free Chlamydia How-To Implementation Guide for Healthcare Providers, visit the National Chlamydia Coalition website at http://chlamydiacoalition.org.
The largest growing populations for chlamydia are teens and young adults aged 15 to 24. Through annual screening – a simple urine test in your office or in an off-site lab – you can help teens and young adults maintain good health.
Chlamydia Screening in Women (CHL): HEDIS® recommends annual screenings for teens starting at age 16 and for women up to age 24. Sexually active teens, young adults, and women should be tested each calendar year as well as women who have:
- Made comments or talked to you about sexual relations
- Had a pregnancy test
- Been prescribed birth control (even if used for acne treatment)
- Received gynecological services
- A history of sexually transmitted diseases
- A history of sexual assault or abuse
Description
|
CPT Codes
|
Chlamydia tests
|
87110, 87270, 87320, 87490, 87491, 87492, 87810
|
Pregnancy test exclusion
|
81025, 84702, 84703
|
The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand members’ rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem has adopted a member rights and responsibilities statement.
To read the member rights and responsibilities statement, visit the Policies, Guidelines and Manuals page of our provider website. Scroll down the page and select “Read about member rights.” Under the FAQ question titled “Laws and Rights that Protect You” you can find information about Anthem member rights and responsibilities.
Practitioners may access the FEP member portal at fepblue.org/memberrights to view the FEPDO Member Rights Statement.
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem is taking this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.
Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. We urge all practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.
We expect all health care practitioners to:
- Discuss with the patient the importance of communicating with other treating practitioners
- Obtain a signed release from the patient and file a copy in the medical record
- Document in the medical record if the patient refuses to sign a release
- Document in the medical record if you request a consultation
- If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner
- Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
- Diagnosis
- Treatment plan
- Referrals
- Psychopharmacological medication (as applicable)
In an effort to facilitate coordination of care, we have several tools available on our anthem.com Provider website for behavioral health and other medical practitioners including:
- Coordination of Care Form
- Coordination of Care Letter Template - Behavioral Health
- Coordination of Care Letter Template - Medical
The following behavioral health forms, brochures, and screening tools for substance abuse and attention-deficit/hyperactivity disorder (ADHD) are also available on our anthem.com Provider website:
- Alcohol Use Assessment Brochure
- Antidepressant Medication Management
- Edinburgh Postnatal Depression Scale
- Opioid Use Assessment Brochure
- Substance Brief Intervention/Referral Tool (SBIRT)
- Vanderbilt ADHD Diagnostic Parent Rating Scale
Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.
Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals who are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.
Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.
Contact us
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research.
All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/providers > For Providers > under Provider Resources, select Policies, Guidelines & Manuals > scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.
Anthem utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Our medical policies are available on Anthem’s website at anthem.com.
You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. UM criteria are also available on the web. Just go to anthem.com, and select Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies and Clinical UM Guidelines.
We work with providers to answer questions about the utilization management process and the authorization of care. Here’s how the process works:
- Call us toll free from 8:30 a.m. to 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
- If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after 12 midnight will be returned the same business day.
- Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.
The following phone numbers are for physicians and their staffs. Members should call the customer service number on their health plan ID card.
To Discuss UM Process and Authorizations
|
To Discuss Peer-to-Peer UM Denials w/Physician
|
To Request UM Criteria
|
TTY/TDD
|
800-392-1016
Transplant
800-255-0881
National Transplant
844-644-8101
Fax: 888-438-7051
Behavioral Health
800-755-0851
Autism
844-269-0538
FEP
800-860-2156
UM Fax: 800-732-8318
ABD Fax: 877-606-3807
|
800-437-7162
Adaptive Behavioral Treatment
844-269-0538
FEP
800-860-2156
|
800-437-7162
FEP
800-860-2156
UM Fax: 800-732-8318
ABD Fax: 877-606-3807
|
711, or
TTY/Voice: 800-457-1220
|
For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.
Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.
You may already be familiar with the Availity multi-payer Authorization app because thousands of providers are already using it to submit prior authorizations for other payers. Anthem is eager to make it available to our providers, too. On December 13, 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 us.
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 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, you can still access 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 available
If you aren’t already familiar with the Availity Authorization app, training is available on the following dates:
Wednesday, December 1, 11 a.m.
Wednesday, December 8, Noon
Friday, December 17, 2:30 p.m.
Wednesday, January 5, 11 a.m.
Tuesday, January 11, 3 p.m.
You can always log onto Availity.com and view the webinar at your convenience. From Help & Training select Get Trained to access the Availity Learning Center. You can use “AvAuthRef” for a keyword search or select the Session tab to see all upcoming live webinars.
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 Authorizations and Referrals.
When you use the Availity Authorization app, you will know if a prior authorization is required in six easy steps and in fewer than five minutes. If a prior authorization is not needed, the message “No Auth Required” will return. This submission will be saved to your dashboard for future reference. If authorization is needed, just continue with the prior authorization submission. The entire submission process takes less time than it would to send an authorization by fax and is much quicker than chatting with provider services.
Did you know that digital authorizations are considered a high priority? Submitting your pressing authorizations through the Availity Authorization app augments our process, helping to reduce unnecessary delays to your patient’s care.
You can now submit prior authorizations in one place for all payers. The Availity Authorization app is multi-payer. This means you no longer have to toggle between Anthem’s Interactive Care Reviewer (ICR) and the Availity Authorization app to submit apps for all payers.
AIM authorization for radiology services? No problem! The Availity Authorization app is set up for radiology service authorization submissions. Coming in 2022, you can submit all of your AIM authorizations through the app.
Access the Availity Authorization app for Anthem submissions on December 13, 2021. Log onto Availity.com on December 13, 2021, and select the Authorizations app from the home screen or use the Patient Registration tab to select Authorizations & Referrals through the multi-payer app.
ICR is still accessible to review previously submitted authorizations. You will also continue to use ICR for behavioral health authorizations, FEP authorizations and authorizations for medical specialty Rx. Until we fully integrate Anthem-specific functions in the Availity Authorization app, you will also continue to use ICR for appeals as well.
How do you access ICR? That’s easy, too. We have added a landing page in the Availity Authorization app that offers a direct link to your ICR dashboard. Just select the Reserved Auth/Appeals button on the landing page.
Not familiar with the Availity Authorization app? Training is convenient and available through live webinars or recorded sessions for self-service learning. To sign-up for training log onto Availity.com and from the top toolbar select Help & Training then Get Trained. Use “AvAuthRef” in the search bar or select the Session tab to see all upcoming live webinars.
Availity Authorization app training schedule:
Wednesday, December 1, 11 a.m.
Wednesday, December 8, Noon
Friday, December 17, 2:30 p.m.
Wednesday, January 5, 11 a.m.
Tuesday, January 11, 3 p.m.
Give it a try! If you’re not enrolled on Availity go to Availity.com/provider-portal-registration. Availity is free to Anthem providers, saves time, reduces costs and offers a seamless digital transaction experience.
Effective November 1, 2021, EnrollSafe is available as the electronic funds transfer (EFT) enrollment portal for providers participating with Anthem. CAQH Enrollhub is no longer offering EFT enrollment to new users.
CAQH Enrollhub is the only CAQH tool decommissioned. All other CAQH tools are not impacted.
EnrollSafe: Secure and available 24-hours a day
If you need to change an EFT enrollment previously submitted through CAQH, or enroll a new bank account for EFT, visit the EnrollSafe portal at https://enrollsafe.payeehub.org and select “Register.” Once you have completed registration, you’ll be directed through the EnrollSafe secure portal to the enrollment page. There, you’ll provide the required information to receive direct payment deposits. There is no fee to register for EFT via EnrollSafe.
Already enrolled in EFT through CAQH Enrollhub?
Please note if you’re already enrolled in EFT through CAQH Enrollhub, no action is needed. Your EFT enrollment information is not changing as a result of the new enrollment hub.
If you ever need to make changes to your bank account, use EnrollSafe going forward to update your EFT bank account information.
We’re here to help – EFT and ERA registration and contact information
Type of transaction
|
How to register, update, or cancel
|
For registration related questions
|
To resolve issues after registration
|
EFT only
|
Use EnrollSafe
|
EnrollSafe help desk at
877-882-0384
Available Monday – Friday,
9 a.m. to 8 p.m. ET, except public and/or bank holidays.
Email: Support@payeehub.org
|
EnrollSafe help desk at
877-882-0384
Available Monday – Friday,
9 a.m. to 8 p.m. ET, except public and/or bank holidays.
Email: Support@payeehub.org
|
ERA (835) only
|
Use Availity
|
Availity Support: 800-282-4548
|
Availity Support: 800-282-4548
NOTE: Allow up to 10 business days for ERA enrollment processing.
|
The annual behavioral health access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded during the first through third quarters of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine follow-ups.
The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e. incorrect or non-working phone numbers; practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only, or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.
The primary appointment type not meeting compliance is consistently obtaining the initial routine appointment. This is the initial conversation with a professional after the intake assessment for a new patient for a non-urgent condition. Please refer to compliant timeframe and explanation below.
To be compliant, per the Provider Manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:
- Non-life-threatening emergency – The patient must meet with their BH practitioner, another practitioner in the practice or a covering practitioner within 6 hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
- Explanation - These calls concern members in acute distress whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
- Urgent – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 48 hours.
- Explanation - These calls are non-emergent with significant psychological distress when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
- Initial routine office visit – A new patient must meet with a designated BH practitioner or another equivalent practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating practitioner.
- Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms which presents no immediate distress, and can wait to schedule an appointment without any adverse outcomes.
- Routine office visit – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 30 calendar days.
- Explanation - These calls concern existing members to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
- BH follow-up appointment after discharge – The patient must meet with their practitioner or another practitioner in the practice within 7 calendar days.
- Explanation – These calls concern members being released from inpatient psychiatric hospital care requesting a follow-up appointment to evaluate what has taken place since release, including med management.
Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® (AIM) Musculoskeletal Interventional Pain Management Clinical Appropriateness Guideline. As part of the AIM guideline annual review process, the following updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Epidural injection procedures (ESI) and diagnostic selective nerve root blocks (SNRB):
- Allow more frequent ESI in newly diagnosed patients
- Remove imaging requirement in certain circumstances
- Require similar criteria as ESI for diagnostic SNRB
- Add epidural abscess as a contraindication
- Limit multilevel and combination diagnostic SNRB
Paravertebral facet injection/medial branch block (MBB)/neurolysis:
- Limit indefinite use of diagnostic MBB
- Add indication for diagnostic pars defect MBB
- Expand exceptions allowed for intraarticular facet injections
- Define MBB timing with respect to radiofrequency neurotomy, MBB limited to RFA candidacy
- Limit open surgical neurolysis, and limited multiple spinal injections
Sacroiliac joint injections:
- Limit indefinite use of diagnostic intraarticular injections
- Disallow sacral lateral branch blocks
- Disallow sacroiliac joint therapeutic injections in a previously fused joint
Spinal cord and nerve root stimulators:
- Allow minimally invasive pain procedures to satisfy conservative management definition
- Specify timing of mental health evaluation
- Define indications for repeat stimulator trial
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at www.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 AIM via the Availity Web Portal at www.availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday – Friday, 8 a.m. – 5 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.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 13, 2022, the following updates will apply to the AIM Specialty Health® (AIM) Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Diagnostic coronary angiography
- Removed indications for asymptomatic patients (in alignment with the ISCHEMIA trial)
- Facilitated coronary angiography with a view to intervention in non-culprit vessels following ST-segment elevation myocardial infarction (STEMI), (in alignment with the COMPLETE trial)
- For patients undergoing preoperative evaluation for TAVR or other valve surgery, aligned criteria with the updated ACC/AHA Guideline for the management of patients with valvular heart disease
Percutaneous coronary intervention
- Revised criteria such that, for some cohorts, only those patients with persistent unacceptable symptoms and moderate or severe stress test abnormalities can proceed to revascularization (in alignment with the ISCHEMIA trial)
- For non-left main percutaneous coronary intervention (PCI), expanded use to non-culprit vessels in patients following ST-segment elevation myocardial infarction (STEMI), and restricted use to those with moderate or severe stress test abnormalities who have failed medical therapy
- Left main PCI limited to situations where coronary artery bypass grafting (CABG) is contraindicated or refused (in alignment with NOBLE and EXCEL trials)
- Clarified requirements for patients who have undergone CABG: at least 70% luminal narrowing qualifies as stenosis, symptomatic ventricular tachycardia is considered an ischemic symptom, and instant wave-free ratio fractional flow reserve (iFR) is considered in noninvasive testing
- Removed requirement to calculate SYNTAX score for patients scheduled to undergo renal transplantation
- For patients scheduled for percutaneous valvular procedures (e.g., transcatheter aortic valve replacement/implantation (TAVR/TAVI) or mitral valve repair), added clarification that PCI should only be attempted for complex triple vessel disease when CABG is not an option.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at www.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 AIM via the Availity Web Portal at www.availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday – Friday, 8 a.m. – 5 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.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 13, 2022, the following updates will apply to the AIM Specialty Health® (AIM) Radiation Therapy and Proton Beam Therapy Clinical Appropriateness Guideline. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services
- Removed Eastern Cooperative Oncology Group (ECOG) status as definition for performance status throughout guidelines.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at www.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 AIM via the Availity Web Portal at www.availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday – Friday, 8 a.m. – 5 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.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 13, 2022, the following guideline updates will apply to the AIM Specialty Health® (AIM) Advanced Imaging Clinical Appropriateness Guideline. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services
Imaging of the brain
- Acoustic neuroma – removed indication for CT brain and replaced with CT temporal bone
- Meningioma – new guideline establishing follow-up intervals
- Pituitary adenoma – removed allowance for CT following nondiagnostic MRI in macroadenoma
- Tumor, not otherwise specified – added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features
Imaging of the head and neck
- Parathyroid adenoma – specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
- Temporomandibular joint dysfunction – specified duration of required conservative management
Imaging of the heart
- Coronary CT angiography – removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
Imaging of the chest
- Pneumonia – removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
- Pulmonary nodule – aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
Imaging of the abdomen and pelvis
- Uterine leiomyomata – new requirement for US prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
- Intussusception – removed as a standalone indication
- Jaundice – added requirement for US prior to advanced imaging in pediatric patients
- Sacroiliitis – defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
- Azotemia – removed as a standalone indication
- Hematuria – modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
- Diffuse liver disease – new indication for multiparametric MRI for fibrosis and hemochromatosis
Oncologic imaging
- National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin & non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers
- Cancer screening: new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
- Breast cancer: clinical scenario clarifications for diagnostic breast MRI and PET/CT
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at www.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 AIM via the Availity Web Portal at www.availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday – Friday, 8 a.m. – 5 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning with dates of service on or after March 1, 2022, the Assistant Surgeon Services commercial reimbursement policy will be renamed Assistant at Surgery (Modifier 80, 81, 82, AS). This policy follows the Centers for Medicare & Medicaid Services (CMS) guidelines for the codes designated as Medicare Physician Fee Schedule (MPFS) Assistant Surgery payment indicator ‘2’ (“Always” requiring an assistant surgeon). Codes identified with MPFS Assistant Surgery payment indicators ‘0’, ‘1’, and ‘9’ are not allowed for reimbursement. Additionally, the Assistant Surgeon Coding list will be retired.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
Beginning with dates of service on or after January 1, 2022, Anthem’s Virtual Visits commercial reimbursement policy will be updated to add the following:
- Place of service 10 (telehealth provided in patient’s home)
- Place of service 02 (telehealth provided other than in patient’s home)
Services reported by a professional provider with a place of service 02 or 10 will be eligible for non-office place of service reimbursement.
These correct coding updates align with the telehealth place of service updates released by the Centers for Medicare & Medicaid Services (CMS).
Additionally, the Related Coding section of the policy is updated to clarify that for Q3014, the member must be physically present in the originating facility.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
Beginning with dates of service on or after March 1, 2022, Anthem’s Co-Surgeon/Team Surgeon Services commercial reimbursement policy will be retired and replaced with the following reimbursement policies:
- Modifier 62: Co-Surgeon Services – professional: Under this reimbursement policy, Anthem allows reimbursement of procedures eligible for co-surgeons when billed with modifier 62. We follow the Centers for Medicare & Medicaid Services (CMS) Medicare Physician Fee Schedule (MPFS) Co-Surgery payment indicators and will allow services requiring a co-surgeon billed with CMS MPFS payment indicator ‘2’ (always) and will deny services billed with indicator ‘0’ (never), ‘1’ (sometimes) and ‘9’ (not applicable). Reimbursement for each surgeon is based on 63 percent of the applicable fee schedule or contracted/negotiated rate.
- Modifier 66: Surgical Teams – professional: Under this reimbursement policy, Anthem allows the of procedures eligible for surgical teams when billed with modifier 66. We follow the CMS MPFS Team Surgery payment indicators and will allow services requiring team surgery billed with CMS MPFS payment indicator ‘1’ (sometimes) and ‘2’ (always), and will deny services billed with the indicator ‘0’ (never) and ‘9’ (not applicable).
For more information about these policies, visit the Reimbursement Policies page at anthem.com.
In the September 2021 edition of Provider News, we announced that a new commercial reimbursement policy titled ‘Inpatient Facility Transfers - facility’ would be effective for dates of service on or after December 1, 2021. We have made a decision to retract this reimbursement policy.
The following clinical criteria documents were endorsed at the August 20, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.
Revised clinical criteria effective October 1, 2021
The following criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0020 Tysabri (natalizumab)
Revised clinical criteria effective October 7, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0007 Synagis (palivizumab)
Revised clinical criteria effective November 1, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0167 Rituximab Agents for Oncologic Indications
The following clinical criteria documents were endorsed at the September 22, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.
Revised clinical criteria effective October 4, 2021
The following criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0197 Jemperli (dostarlimab-gxly)
Revised clinical criteria effective October 25, 2021
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0008 Subcutaneous Hormonal Implants
- ING-CC-0013 Mepsevii (vestronidase alfa)
- ING-CC-0015 Infertility and HCG Agents
- ING-CC-0022 Vimizim (elosulfase alfa)
- ING-CC-0023 Naglazyme (galsulfase)
- ING-CC-0024 Elaprase (idursulfase)
- ING-CC-0025 Aldurazyme (laronidase)
- ING-CC-0027 Denosumab Agents
- ING-CC-0028 Benlysta (belimumab)
- ING-CC-0046 Zinplava (bezlotoxumab)
- ING-CC-0078 Orencia (abatacept)
Revised clinical criteria effective March 1, 2022
The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0012 Brineura (cerliponase alfa)
- ING-CC-0017 Xiaflex (collagenase clostridium histolyticum) injection
- ING-CC-0018 Agents for Pompe Disease
- ING-CC-0021 Fabrazyme (agalsidase beta)
- ING-CC-0034 Hereditary Angioedema Agents
- ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0100 Istodax (romidepsin)
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0128 Tecentriq (atezolizumab)
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 AIM Specialty Health® (AIM), a separate company.
Please note that 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
Effective for dates of service on and after March 1, 2022, 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.
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
*ING-CC-0018
|
J3490, J3590, C9399
|
Nexviazyme (avalglucosidase alfa-ngpt)
|
*ING-CC-0034
|
J1744
|
Sajazir (icatibant)
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
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 March 1, 2022, 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 prior authorization updates.
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
*ING-CC-0018
|
J3490, J3590, C9399
|
Nexviazyme (avalglucosidase alfa-ngpt)
|
*ING-CC-0034
|
J1744
|
Sajazir (icatibant)
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Visit Pharmacy Information for Providers on anthem.com 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
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override.
For additional information, please review the Drug Screen Testing reimbursement policy at https://www.anthem.com/medicareprovider.
Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.
Updates by guideline:
Imaging of the brain:
- Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
- Meningioma — new guideline establishing follow-up intervals
- Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
- Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features
Imaging of the head and neck:
- Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
- Temporomandibular joint dysfunction — specified duration of required conservative management
Imaging of the heart:
- Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
Imaging of the chest:
- Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
- Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
Imaging of the abdomen and pelvis:
- Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
- Intussusception — removed as a standalone indication
- Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
- Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
- Azotemia — removed as a standalone indication
- Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
Oncologic imaging:
- National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
- Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
- Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM via:
- AIM’s ProviderPortalSM directly at www.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.
- Availity* Portal at www.availity.com.
- Phone at 800-714-0040, Monday through Friday from 6 a.m. to 6 p.m.
If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.
We are pleased to announce a new no-cost care management program available for your Medicare Advantage covered patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD). This high-touch program, delivered by Somatus*, is designed to support and enhance your existing patient care by providing hands-on, one-on-one care management to eligible patients with kidney disease.
Somatus is the leading and largest provider of kidney care management services in the country. Through an innovative care-delivery model, Somatus surrounds patients with access to the full suite of support services and education needed to delay kidney disease progression and retain quality of life.
Somatus’ care management services are personalized to each participating member and may include:
- A full care team comprised of a nurse, community health worker, pharmacist, dietitian, and social worker.
- Ongoing in-home physical assessments, environmental assessments, face-to-face education, and health coaching to identify problems early and avoid potential hospitalizations and complications.
- Comprehensive 1:1 care management of the patient’s kidney disease and co-morbidities, delivered in person (at home, clinic, or hospital) or via telephone.
- Clinical and logistical assistance to help patients transfer safely from hospital to home, if needed.
- Meal planning, appointment scheduling, transportation coordination, connection to local resources and community-based organizations, and more.
AMH Health, LLC will identify Medicare Advantage patients in your practice that qualify for and would benefit from Somatus’ kidney-care services, and we look forward to working with you to help ensure these patients enroll and take part in this no-cost opportunity. A member of the Somatus team will be in touch to discuss your eligible patients and how you can help encourage their participation.
For more information about Somatus, visit www.somatus.com or, contact the Somatus Care Team at:
- Phone: 855-851-8354, Monday through Friday, 9 a.m. to 9 p.m. ET
- Email: care@somatus.com
Beginning January 1, 2022, Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans (MMPs) are responsible for adjudicating claims for COVID-19 vaccines and their administration and for COVID-19 monoclonal antibodies and their administration.
We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.
Below are images reflecting the scenarios that have been enhanced:
Paper remittance

Electronic remittance advice (ERA/835)
  
What has changed?
- Non-payment number display in the Check Number and Check/EFT Number fields:
- Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
- Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.
- Searching for non-payment remittance:
- Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
- Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.
The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.
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