 Provider News MaineFebruary 2020 Anthem Maine Provider NewsBeginning May 1, 2020, claims for laboratory services subject to the Clinical Laboratory Improvement Amendments (CLIA) 1988 federal statute and regulations must include the following information to be considered for payment.
A valid CLIA Certificate Identification number is required for reimbursement of clinical laboratory services reported on a CMS-1500 claim form (or its electronic equivalent) beginning May 1, 2020. The CLIA Certificate Identification number must be submitted in one of the following ways:
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Claim Format and Elements
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CLIA Number Location Options
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Referring Provider Name and National Provider Identifier (NPI) Number Location Options
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CMS-1500
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Must be represented in field 23
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Submit the referring provider name and NPI number in fields 17 and 17b, respectively.
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Electronic transaction 837 Professional; Health Insurance Portability and Accountability Act (HIPAA) Version 5010
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Must be represented in the 2300 loop, REF02 element, with qualifier of “X4” in REF01
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Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.
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Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the “QW” modifier when any CLIA Waived laboratory service is reported on a CMS-1500 claim form in order for the procedure to be evaluated to determine eligibility for benefit coverage.
Laboratory procedures are only covered and therefore payable if rendered by an appropriately licensed or certified laboratory. Therefore, any claim that does not contain the CLIA ID will be considered incomplete and rejected beginning May 1, 2020.
If you have additional questions, please call the telephone number on the back of the member’s identification card. We are collaborating with leading organizations on a new school-based initiative called Shine Light on Depression to help tackle the issue of teen depression and suicide in middle and high school youth nationwide. The Shine Light on Depression e-toolkit (e.g., website) will provide school communities with free, ready-to-use tools designed to raise awareness of depression and suicide prevention in a positive, fact-based, and inclusive manner. This approach will help build a community in which there is open discussion and appropriate vocabulary about the subject of depression and places it in the broader context of good mental health. The e-toolkit features customizable classroom lessons to empower educators to lead effective depression awareness programs, family-community workshop materials to help adults and families talk about how to support teens, and teen club resources that empower students to lead activities and help each other by talking and listening. With 24,053 secondary schools in the U.S., the Shine Light on Depression e-toolkit has the potential to impact large numbers of individuals who are at risk of depression and suicide and support schools in meeting state teaching mandates. Visit Shine Light on Depression to learn more.
Shine Light on Depression is a unique collaboration of organizations committed to raising awareness of depression and suicide prevention among young people: American School Health Association, Anthem, Inc., Erika’s Lighthouse, JetBlue Airways Corporation and the National Parent Teachers Association. We contract with Inovalon, an independent company that provides secure, clinical documentation services, to help us comply with provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk level and report to CMS on those conditions. Your offices have been receiving Inovalon SOAP (Subjective, Objective, Assessment and Plan – these are health assessments) packets all year long as part of our risk adjustment cycle, asking for the physicians’ help with completing health assessments for some of their patients who are our members.
Incentives for submitting SOAPs/Health Assessments
SOAPs submitted as paper are eligible for a $50 incentive; SOAPs submitted electronically through Inovalon’s ePASS system are eligible for a $100 incentive.
Submission deadline and important reminder
While the dates of service for the patient visits must have been by December 31, 2019, the SOAP notes/Health Assessments can be submitted up until February 15, 2020. We will still pay the incentive payments for these submissions through February 15, 2020.
Questions or assistance with SOAPs
Need help with ePASS or have questions? Simply email your inquiry to Inovalon at ePASSsupport@inovalon.com with your name, organization, contact information, and any questions that you might have. Trained representatives are available to assist you. If you prefer to reach Inovalon by phone, please call 877-448-8125, Monday - Friday, 8:00 a.m. - 9:00 p.m.; Saturday - Sunday, 10:00 a.m. - 6:00 p.m.
If you have any questions regarding our risk adjustment process, please contact Alicia Estrada, our Commercial Risk Adjustment Network Education Representative who supports your area, at Alicia.Estrada@anthem.com. Please note that we no longer manage traditional behavioral health outpatient therapy for all fully-insured products, including our health insurance exchange products. Many of our self-funded groups have also removed review of the traditional outpatient therapy visits; however, some groups continue to require a review after a certain number of pass-through visits. With the new calendar year, please be certain to verify benefits for new patients to help ensure you are aware of any requirements. Partial hospitalization, intensive outpatient, applied behavior analysis, trans-cranial magnetic stimulation (TMS) services continue to require prior authorization from the first visit. The following new and revised medical policies were endorsed at the November 7, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies.
Revised medical policies effective November 12, 2019
(The following policies were revised to expand medical necessity indications or criteria.)
- ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
- BEH.00002 - Transcranial Magnetic Stimulation
- MED.00124 - Tisagenlecleucel (Kymriah®)
- SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
Archived medical policy effective December 14, 2019
(The following policy has been archived and has been replaced by AIM guidelines.)
- RAD.00054 - MRI of the Bone Marrow
Revised medical policies effective December 18, 2019
(The following policies were revised to expand medical necessity indications or criteria.)
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- SURG.00127 - Sacroiliac Joint Fusion
- TRANS.00033 - Heart Transplantation
Revised medical policies effective December 18, 2019
(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- ADMIN.00001 - Medical Policy Formation
- DME.00025 - Self-Operated Spinal Unloading Devices
- GENE.00016 - Gene Expression Profiling for Colorectal Cancer
- GENE.00034 - SensiGene™ Fetal RHD genotyping
- GENE.00036 - Genetic Testing for Hereditary Pancreatitis
- GENE.00037 - Genetic Testing for Macular Degeneration
- GENE.00039 - Genetic Testing for Frontotemporal Dementia
- GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
- LAB.00024 - Immune Cell Function Assay
- LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
- LAB.00034 - Serological Testing for Helicobacter Pylori
- LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- MED.00002 - Selected Sleep Testing Services
- MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
- MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
- MED.00065 - Hepatic Activation Therapy
- MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
- MED.00091 – Rhinophototherapy
- MED.00092 - Automated Nerve Conduction Testing
- MED.00097 - Neural Therapy
- MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, and Soft Tissue Grafting, and Regenerative Therapy
- MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
- MED.00116 - Near-Infrared Brain Screening for Hematoma Detection
- MED.00121 - Implantable Interstitial Glucose Sensors
- MED.00122 - Wilderness Programs including Adventure Therapy
- MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
- MED.00128 - Insulin Potentiation Therapy
- RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
- RAD.00036 - MRI of the Breast
- RAD.00053 - Cervical and Thoracic Discography
- RAD.00065 - Radiostereometric Analysis
- REHAB.00003 - Hippotherapy
- SURG.00019 - Transmyocardial Revascularization
- SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
- SURG.00073 - Epiduroscopy
- SURG.00079 - Nasal Valve Suspension
- SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
- SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
- SURG.00100 - Cryoblation for Plantar Fasciitis and Plantar Fibroma
- SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
- SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00111 - Axial Lumbar Interbody Fusion
- SURG.00112 - Occipital Nerve and Supraorbital Nerve Stimulation
- SURG.00121 - Transcatheter Heart Valve Procedures
- SURG.00123 - Transmyocardial/perventricular Device Closure of a Ventricular Septal Defect
- SURG.00130 - Annulus Closure After Discectomy
- SURG.00138 - Laser Treatment of Onychomycosis
- SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- SURG.00146 - Extracorporeal Carbon Dioxide Removal
- THER-RAD.00008 - Neutron Beam Radiotherapy
- THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
- TRANS.00004 - Cell Transplantation (Adrenal-Brain, Fetal Mesencephalic, and Fetal Xenograft)
- TRANS.00008 - Liver Transplantation
- TRANS.00009 - Lung and Lobar Transplantation
- TRANS.00010 - Autologous and Allogenic Pancreatic Islet Cell Transplant
- TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
- TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
- TRANS.00026 - Heart-Lung Transplantation
- TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
- TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
- TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
Revised medical policies effective January 1, 2020
(The following policies were updated with new procedure and/or diagnosis codes.)
- GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
- GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
- GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00026 - Cell-Free Expression Profiling of Melanomas
- LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
- MED.00125 - Biofeedback and Neurofeedback
- RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
- RAD.00057 - Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
- SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
- SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- SURG.00150 - Leadless Pacemaker
- SURG.00153 - Cardiac Contractility Modulation Therapy
Revised medical policy effective February 5, 2020
(The following policy was reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
Archived medical policies effective February 5, 2020
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing (Recategorized to CG-GENE-20)
- GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers (Recategorized to CG-GENE-19)
- MED.00109 - Corneal Collagen Cross-Linking (Recategorized as CG-SURG-105)
- RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications (Recategorized as CG-MED-87)
- SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (Recategorized as CG-SURG-106)
Archived medical policies effective February 5, 2020
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- GENE.00001 - Genetic Testing for Cancer Susceptibility (Recategorized to CG-GENE-14. For panels see GENE.00052)
- GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent (Recategorized to CG-GENE-13. For panels see GENE.00052)
- GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility (Recategorized to CG-GENE-15. For panels see GENE.00052)
- GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome (Recategorized to CG-GENE-16. For panels see GENE.00052)
- GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility (Recategorized to CG-GENE-17. For panels see GENE.00052)
- GENE.00035 - Genetic Testing for TP53 Mutations (Recategorized to CG-GENE-18. For panels see GENE.00052)
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases (Recategorized to CG-GENE-13. For panels see GENE.00052)
Archived medical policies effective February 5, 2020
[The following policies has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.]
- MED.00123 - Axicabtagene ciloleucel (Yescarta®) [transitioned as ING-CC-0051]
- MED.00124 - Tisagenlecleucel (Kymriah®) [transitioned as ING-CC-0150]
New medical policy effective February 5, 2020
(The policy below is new and had no significant changes to the policy position or criteria.)
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling (Gene panel codes moved from GENE.00001, GENE.00012, GENE.00025, GENE.00028, GENE.00029, GENE.00030, GENE.00035, and GENE.00043)
Revised medical policies effective May 1, 2020
(The following policies listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)
- GENE.00025 - Proteogenomic Testing for the Evaluation of Malignancies
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
- SURG.00007 - Vagus Nerve Stimulation
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
The following new and revised medical policies were endorsed at the November 7, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Revised clinical guideline effective December 18, 2019
(The following guideline was revised to expand medical necessity indications or criteria.)
- CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
Revised clinical guidelines effective December 18, 2019
(The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- CG-ANC-04 - Ambulance Services; Air and Water
- CG-ANC-07 - Inpatient Interfacility Transfers
- CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
- CG-BEH-14 - Intensive In-Home Behavioral Health Services
- CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
- CG-DME-10 - Durable Medical Equipment
- CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, with or without Power Seating Systems, and Power Operated Vehicles (POVs)
- CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
- CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
- CG-LAB-13 - Skin Nerve Fiber Density Testing
- CG-MED-19 - Custodial Care
- CG-MED-23 - Home Health
- CG-MED-26 - Neonatal Levels of Care
- CG-MED-38 - Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
- CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
- CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
- CG-OR.PR-05 - Myoelectric Upper Extremity Prosthetic Devices
- CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- CG-SURG-27 - Gender Reassignment Surgery
- CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-71 - Reduction Mammoplasty
- CG-SURG-72 - Endothelial Keratoplasty
- CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-SURG-77 - Refractive Surgery
- CG-SURG-94 - Keratoprosthesis
- CG-SURG-95 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention
- CG-SURG-96 - Intraocular Telescope
- CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Non-Coronary)
Archived clinical guideline effective December 18, 2019
(The following adopted clinical guideline has been archived and its content has been transferred to an existing Clinical UM Guideline.)
- CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver (combined with CG-SURG-61)
Revised clinical guidelines effective January 1, 2020
(The following guidelines were updated with new procedure and/or diagnosis codes.)
- CG-DME-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
- CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
- CG-MED-77 - SPECT/CT Fusion Imaging
- CG-REHAB-11 - Cognitive Rehabilitation
- CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
Adopted clinical guidelines effective February 5, 2020
(The following guidelines were previously medical policies and have been adopted with no significant changes.)
- CG-GENE-13 - Genetic Testing for Inherited Diseases (previously GENE.00012 and GENE.00043)
- CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
- CG-GENE-15 - Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis (previously GENE.00028)
- CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome (previously GENE.00029)
- CG-GENE-17 - RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility (previously GENE.00030)
- CG-GENE-18 - Genetic Testing for TP53 Mutations (previously GENE.00035)
- CG-GENE-19 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers (previously GENE.00045)
- CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing (previously GENE.00006)
- CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications (previously RAD.00023)
- CG-SURG-105 - Corneal Collagen Cross-Linking (previously MED.00109)
- CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (previously SURG.00122)
Revised clinical guideline effective May 1, 2020
(The following guideline listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)
- CG-GENE-13 - Genetic Testing for Inherited Diseases
- CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
- CG-MED-68 - Therapeutic Apheresis
Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines.
Joint surgery updates by section:
- Shoulder arthroplasty
- Added steroid injection for all joints exclusion based on panel recommendation
- Added exclusions for use of xenografts or biologic scaffold for augmentation or bridging reconstruction, use of platelet rich plasma or other biologics and concomitant subacromial decompression
- Removed indication for subacromial impingement with rotator cuff tear
- Hip arthroplasty
- Added exclusion for steroid injection for joint being replaced within the past 6 weeks
- Added labral tear indication
- Knee arthroscopy and open procedures
- Added chondroplasty indication
- Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella
- Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section
- Code changes
- Added CPT codes 27425, 27570
Spine surgery updates by section:
- No criteria changes - code changes only
- Added CPT codes 0200T, 0201T
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 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 availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 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 May 17, 2020, the following updates will apply to the AIM Advanced Imaging: Vascular Imaging Clinical Appropriateness Guidelines.
Updates by section:
Aneurysm of the abdominal aorta or iliac arteries
- Added new indication for asymptomatic enlargement by imaging
- Clarified surveillance intervals for stable aneurysms as follows:
- Treated with endografts, annually
- Treated with open surgical repair, every 5 years
Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
- Added surveillance indication and interval for surgical bypass grafts
- Access AIM’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.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 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 with dates of service on and after April 1, 2020, and in accordance with the IngenioRx Pharmacy and Therapeutic (P&T) process, we 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 here.
The following clinical criteria documents were endorsed at the November 15, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Revised clinical criteria effective December 16, 2019
The following clinical criteria was revised to expand medical necessity indications or criteria.
- ING-CC-0003: Immunoglobulins
- ING-CC-0041: Complement Inhibitors
- ING-CC-0042: Monoclonal Antibodies to Interleukin-17
- ING-CC-0063: Stelara (ustekinumab)
- ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0075: Rituximab Agents for Non-Oncology Indications
- ING-CC-0124: Keytruda (pembrolizumab)
- ING-CC-0127: Darzalex (daratumumab)
- ING-CC-0128: Tecentriq (atezolizumab)
- ING-CC-0133: Aliqopa (copanlisib)
Revised clinical criteria effective December 16, 2019
The following clinical criteria were reviewed and may have word changes or clarifications, but had no significant changes to the medical necessity indications or criteria.
- ING-CC-0002: Colony Stimulating Factor Agents
- ING-CC-0006: Hyaluronan Injections
- ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0039: GamaSTAN [immune globulin (human)]
- ING-CC-0040: Prialt (ziconotide)
- ING-CC-0043: Monoclonal Antibodies to Interleukin-5
- ING-CC-0047: Trogarzo (ibalizumab-uiyk)
- ING-CC-0049: Radicava (edaravone)
- ING-CC-0062: Tumor Necrosis Factor Antagonists
- ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy
- ING-CC-0074: Akynzeo (fosnetupitant and palonosetron) for Injection
- ING-CC-0079: Strensiq (asfotase alfa)
- ING-CC-0090: Ixempra (ixabepilone)
- ING-CC-0100: Istodax (romidepsin)
- ING-CC-0103: Faslodex (fulvestrant)
- ING-CC-0108: Halaven (eribulin)
- ING-CC-0110: Perjeta (pertuzumab)
- ING-CC-0115: Kadcyla (ado-trastuzumab)
New clinical criteria effective February 5, 2020
The following new clinical criteria was previously a medical policy and was revised to expand medical necessity indications or criteria.
- ING-CC-0151: Yescarta (axicabtagene ciloleucel) (previously MED.00123)
New clinical criteria effective February 5, 2020
The following new clinical criteria was previously a medical policy and was revised with no significant change to the medical necessity indications or criteria.
- ING-CC-0150: Kymriah (tisagenlecleucel) (previously MED.00124)
Revised clinical criteria effective May 1, 2020
The following current 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-0002: Colony Stimulating Factor Agents
- ING-CC-0003: Immunoglobulins
- ING-CC-0034: Hereditary Angioedema Agents
- ING-CC-0041: Complement Inhibitors
- ING-CC-0042: Monoclonal Antibodies to Interleukin-17
- ING-CC-0043: Monoclonal Antibodies to Interleukin-5
- ING-CC-0048: Spinraza (nusinersen)
- ING-CC-0050: Monoclonal Antibodies to Interleukin-23
- ING-CC-0062: Tumor Necrosis Factor Antagonists
- ING-CC-0063: Stelara (ustekinumab)
- ING-CC-0064: Interleukin-1 Inhibitors
- ING-CC-0065: Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0066: Monoclonal Antibodies to Interleukin-6
- ING-CC-0071: Entyvio (vedolizumab)
- ING-CC-0072: Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
- ING-CC-0078: Orencia (abatacept)
- ING-CC-0150: Kymriah (tisagenlecleucel)
New clinical criteria effective May 1, 2020
The following new clinical criteria had content transferred from existing criteria and was revised with no significant change to the medical necessity indications or criteria.
- ING-CC-0148: Agents for Hemophilia B (content moved from ING-CC-0065)
New clinical criteria effective May 1, 2020
The following new clinical criteria had content transferred from existing criteria and was revised, which might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0149: Select Clotting Agents for Bleeding Disorders (content moved from ING-CC-0065)
Category: Medicare
Effective May 1, 2020, Anthem will update the Modifier 62: Co‑Surgeons reimbursement policy to expand the current policy’s language, adding that we do not consider surgeons performing different procedures during the same surgical session as co-surgeons, and Modifier 62 is not required.
Assistant surgeon and/or multiple procedures rules and fee reductions apply if a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session.
Please note that assistant surgeon rules do not apply to procedures appropriately billed with Modifier 62.
Please visit www.anthem.com/medicareprovider to view the Modifier 62: Co-Surgeons reimbursement policy for additional information regarding percentages and reimbursement criteria.
Category: Medicare
The Centers for Medicare & Medicaid Services (CMS) requires that all hospitals and critical access hospitals (CAHs) provide written notification and an oral explanation to individuals receiving observation services as outpatients for more than 24 hours.
Hospitals should use the OMB-approved standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611. All hospitals and CAHs are still required to provide this statutorily required notification. The notice and accompanying instructions are available at https://go.cms.gov/391jZH9.
The MOON was developed to inform all Medicare beneficiaries, including Anthem Blue Cross and Blue Shield and AMH Health, LLC members, when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH. The notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services.
Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged or admitted.
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