 Provider News MaineJanuary 2022 Anthem Maine Provider NewsContentsAnthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 Notices of material changes/amendments to contractAnthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 Well-child visits: Know the numbersAnthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 Medical policy and clinical guideline updatesAnthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 BlueHPN network live in Maine for 2022Anthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 2022 FEP® benefit information available onlineAnthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Reducing the burden of medical record review and improving health outcomes with HEDIS ECDS reportingAnthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Professional claims - billing referring provider and NPI for home infusion therapy and ambulatory infusion suiteAnthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Important update on Botox® for Medicare members of AMH Health, LLCAnthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Keep up with Medicare newsTo view this publication online:Visit https://providernews.anthem.com/maine/publications/january-2022-anthem-maine-provider-news-1223 Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 Notices of material changes/amendments to contractNotices of material changes/amendments to contract may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements. In this issue, please reference the following article:
To view this article online:Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 Well-child visits: Know the numbersParents may not understand the importance of taking their children to the doctor when they are healthy. The benefits are documented by the American Academy of Pediatrics (AAP)1 as well as the Centers for Disease Control and Prevention2 and it all starts with a recommendation by you, the trusted physician. Share these benefits with parents during regularly scheduled well-visits, or even during sick visits, to reinforce the importance of staying on track:
Measure up: Well-child visits in the first 30 months of life (W30) This HEDIS® measure is described as the percentage of members who had to the following number of well-child visits with a PCP during the last 15 months. These rates are reported:
Tips
Coding
To view this article online:Visit https://providernews.anthem.com/maine/articles/well-child-visits-know-the-numbers-6-9760 Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 Medical policy and clinical guideline updatesThe following new and revised medical policies and clinical guidelines were endorsed at the November 11, 2021, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.
Medical policy updates
Archived medical policies effective November 18, 2021 (The following policies have been archived.)
Revised medical policies effective November 18, 2021 (The following policies were revised to expand medical necessity indications or criteria.)
Archived medical policies effective December 29, 2021 (The following policies have been archived.)
Revised medical policy effective December 29, 2021 (The following policy was revised to expand medical necessity indications or criteria.)
Revised medical policies effective December 29, 2021 (The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
Revised medical policies effective December 29, 2021 (The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
(The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
Revised medical policies effective April 1, 2022 (The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
Revised clinical guideline effective November 18, 2021 (The following adopted guideline was revised to expand medical necessity indications or criteria.)
Unadopted clinical guidelines effective December 1, 2021 (The criteria in the following guidelines will no longer be applied.)
Revised clinical guideline effective December 29, 2021 (The following adopted guideline was revised to expand medical necessity indications or criteria.)
Revised clinical guidelines effective December 29, 2021 (The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
Revised clinical guidelines effective December 29, 2021 (The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
Archived clinical guidelines effective December 29, 2021 (The following guidelines have been archived.)
Unadopted clinical guidelines effective January 1, 2022 (The criteria in the following guidelines will no longer be applied.)
Revised clinical guideline effective April 1, 2022 (The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)
*The applicable policy is attached to this article in PDF format. These, and all Anthem medical policies and clinical guidelines, are also available on our website.
ATTACHMENTS (available on web): SURG.00010 12-29-2021.pdf (pdf - 0.32mb) CG-OR-PR-05 11-18-2021.pdf (pdf - 0.21mb) DME.00044 12-29-2021.pdf (pdf - 0.15mb) MED.00099 12-29-2021.pdf (pdf - 0.23mb) MED.00138 12-29-2021.pdf (pdf - 0.14mb) SURG.00097 12-29-2021.pdf (pdf - 0.22mb) To view this article online:Visit https://providernews.anthem.com/maine/articles/medical-policy-and-clinical-guideline-updates-9-9764 Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 BlueHPN network live in Maine for 2022
BlueHPN® plans offer access to a select set of providers with a record of delivering high-quality, efficient care. BlueHPN networks launched in 2021 in more than 50 markets across the country. Anthem plans with access to the statewide HPN in Maine are live effective January 1, 2022.
Beginning January 1, you may see patients accessing the new statewide HPN network in Maine. Members may be covered through a BlueHPN national employer plan or a local employer’s Pathway HMO plan.
Providers participating in Maine’s Pathway network are included in the BlueHPN network. If you are not sure whether your practice is part of the network, ask your office manager or business office, or contact your Anthem network representative. BlueHPN participation is displayed in provider profiles in our provider directory January 1, 2022.
The simplest way to identify a BlueHPN plan member is by the “BlueHPN” in the suitcase on their member ID card. Below is a sample ID card for a Pathway member in Maine.
To view this article online:Visit https://providernews.anthem.com/maine/articles/bluehpn-network-live-in-maine-for-2022-9768 Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | CommercialDecember 31, 2021 2022 FEP® benefit information available onlineTo view the 2022 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to fepblue.org then click Tools & Resources at the top of the page, and then click Brochures & Resources. Here you will find Plan Brochures, Plan Summaries, and Quick Reference Guides on information for year 2022. For questions, please contact FEP Customer Service at 800-722-0203.
To view this article online:Visit https://providernews.anthem.com/maine/articles/2022-fep-benefit-information-available-online-9-9770 Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Reducing the burden of medical record review and improving health outcomes with HEDIS ECDS reportingThe HEDIS® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality health-care services.
The ECDS Reporting Standard provides a method to collect, and report structured electronic clinical data for HEDIS quality measurement and improvement.
Benefits to providers:
ECDS reporting is part of the National Committee for Quality Assurance’s (NCQA) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures.
Learn more about NCQA’s digital quality system and what it means to you and your practice.
ECDS measures The first publicly reported measure using the HEDIS ECDS Reporting Standard is the Prenatal Immunization Status (PRS) measure. In 2022, NCQA will include the PRS measure in Health Plan Ratings for Medicaid and Commercial plans for measurement year 2021.
For HEDIS measurement year 2022, the following measures can be reported using ECDS:
* Indicates that this is the first year that the measure can be reported using ECDS
Of note, NCQA added the ECDS reporting method to three existing HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening and Follow-up Care for Children Prescribed ADHD Medication. Initially, the ECDS method will be optional, which provides health plans an opportunity to try out reporting using the ECDS method before it is required to transition to ECDS only in the future.
To view this article online:Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Professional claims - billing referring provider and NPI for home infusion therapy and ambulatory infusion suiteEffective December 1, 2021, AMH Health, LLC will prefer the referring physician name and NPI to be included on professional claims for home infusion therapy (HIT) services in fields 17 and 17a on the CMS-1500 claim form.
Providers should report the referring physician information in accordance with the AMH Health guidelines in the Electronic Data Interchange (EDI) Companion Guide for claims submitted electronically.
Thank you for your assistance in our ongoing efforts to promote accurate claims processing and payment. We continue to be dedicated to delivering access to quality care for our members, providing higher value to our customers, and helping improve the health of our communities.
If you have questions regarding this process, contact your Network Manager.
To view this article online:Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Important update on Botox® for Medicare members of AMH Health, LLCEffective January 1, 2022, IngenioRx/CVS Specialty Pharmacy* will no longer distribute the brand name drug Botox®. However, Botox will still be available to AMH Health members through other vendors.
Please note:
For Botox managed under a Medicare member’s part B (medical) benefit Providers should be using buy and bill for any Medicare member who currently receive Botox through their part B (medical) benefit. If your patient is receiving Botox using their part B benefit and is receiving their prescription from IngenioRx/CVS Specialty pharmacy, effective January 1, 2022, IngenioRx/CVS Specialty will no longer filled the prescription. As of January 1, 2022, you will need to buy this drug and bill your patient’s health plan.
If you have questions regarding a Medicare member’s part B benefits, call Provider Services using the information on the back of the member’s ID card.
For Botox managed under a Medicare member’s part D (pharmacy) benefit Effective January 1, 2022, Medicare members who currently receive Botox through IngenioRx/CVS Specialty Pharmacy using their part D (pharmacy) benefit must change to another in-network specialty or retail pharmacy that can obtain and dispense Botox.
If you have questions regarding a Medicare member’s part D benefit, call Pharmacy Member Services using the information on the back of the member’s ID card.
To view this article online:Or scan this QR code with your phone Anthem Blue Cross and Blue Shield | Medicare AdvantageDecember 31, 2021 Keep up with Medicare newsPlease continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including: To view this article online:Visit https://providernews.anthem.com/maine/articles/keep-up-with-medicare-news-242-9780 Or scan this QR code with your phone |
