 Provider News MaineJuly 2021 Maine Provider News Contents State & Federal | Anthem Blue Cross and Blue Shield | Medicare Advantage | July 1, 2021 Let’s Vaccinate
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. We have made the 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.
In June, we announced that the new Strategic Provider System (SPS) would replace our legacy internal provider data management system in July 2021. Please be advised that the launch of SPS has been delayed and will not be implemented in July as originally announced. We will advise you of the new launch date in a future edition of Provider News.
Get ready for the change
The second phase of our improvement will be integration with Availity’s Provider Data Management (PDM) functionality, which will roll out in phases following the launch of SPS. Through this tool, providers will be able to view, maintain, update, and attest provider demographic information is accurate for Anthem (and other health plans) in one easy-to-use portal. Although the launch of SPS has been delayed, if your organization is not already registered on Availity Portal, we strongly encourage you to get started right away. Your organization’s designated administrator can go to Availity.com to register and to find other helpful information about using Availity. Availity is Anthem’s secure provider portal platform where providers can enjoy the convenience of digital transactions including prior authorization submission, claims submission and benefit and eligibility look-up.
Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving Star ratings.
Program objectives:
- Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas including telehealth, pharmacy measures, chronic disease monitoring, cancer screenings, documentation and more.
- Apply the knowledge you gain from the webinars to improve your organization’s quality.
Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.
Register here for our upcoming clinical quality webinars!
More potato chips, sugary drinks and less physical activity are key contributors
In a recent study published by Pediatrics1, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.
The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.
The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.
The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.
- When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
- When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
- Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.
HEDIS® measure WCC looks at the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:
- Body mass index (BMI) percentile (percentage, not value)
- Counseling for nutrition
- Counseling for physical activity
Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.
Code services correctly to measure success
These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:
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Description
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CPT®
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ICD-10-CM
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HCPCS
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BMI percentile
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Z68.51-Z68.54
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Counseling for nutrition
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97802, 97803,
97804
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Z71.3
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G0270, G0271, G0447, S9449, S9452, S9470
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Counseling for physical activity
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Z02.5, Z71.82
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G0447, S9451
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Codes to identify outpatient visits:
CPT: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483
HCPCS: G0402, G0438, G0439, G0463, T1015
It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier! Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.
Self-testing: Measurable difference when correct coding is reflected
This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it. Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.
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Value set ID and subgroup
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Code
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Description
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INR Home Monitoring
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CPT Code 93792
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Patient/caregiver training for initiation of home INR monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results.
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INR Home Monitoring
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CPT Code 93793
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Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab INR test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.
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INR Home Monitoring
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HCPCS Code G0248
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Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results.
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INR Home Monitoring
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HCPCS Code G0249
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Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include four tests.
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INR Home Monitoring
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HCPCS Code G0250
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Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include four tests.
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INR clinical quality measure:
The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.
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Clinical Quality Measure
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Required documentation
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CPT, HCPCS, LOINC and CPT Performance Codes
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Provider Specialty
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INR Monitoring for Individuals on Warfarin*
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Adults 18 years of age and older who have had at least one 56- day interval of warfarin therapy and received at least one INR monitoring test during each 56-day interval with active warfarin therapy in the measurement year. Excludes patients who are monitoring INR at home during the treatment period
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CPT 85610 - Prothrombin time
LOINC 34714-6 INR blood by coagulation assay
6301-6 INR in platelet poor plasma by coagulation assay
38875-1 INR in platelet poor plasma or blood by coagulation assay
46418-0 INR in capillary blood by coagulation assay
52129-4 INR in platelet poor plasma by coagulation - post heparin adsorption
Excludes:
G0248 - demonstrate use home INR monitoring
G0249 - provide test materials and equipment for home INR monitoring
G0250 - physician INR test review interpretation and management
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No provider type restrictions
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We understand it isn’t always easy to know if we are the member’s primary insurance payer. We also want to make it as easy as possible for you to find out so you can avoid claim denials because of not filing the claim within the timely filing guideline.
Before the member even arrives for their appointment, you can check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto Availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for their appointment. After providing services, submit the member’s claim as usual. You can use Availity for that, too, through the Claims & Payments app.
If we are the secondary payer, we will need to receive an explanation of benefits (EOB) along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.
When a claim is submitted to us as the primary payer, and we are the secondary payer, our claims system will deny the claim because we don’t have the EOB. This can cause delays in your receiving payment and can even cause you to miss the timely filing guideline.
For more information about filing claims, visit anthem.com/provider/claims-submissions. For help using Availity, log onto Availity.com and select the Help & Training tab.
Locating a case using Interactive Care Reviewer (ICR), our digital authorization tool just got easier. We added the ICR Case Search tab within the tool so you can find cases submitted through ICR. Cases submitted through both ICR and other sources can still be located using the other search options: Member, Date Range, Reference/Authorization Request Number or Discharge Date.
The steps to access ICR through the Availity Portal have not changed. You are required to have the Authorization & Referral Request role or the Authorization & Referral Inquiry role. Your organization’s Availity administrator can assign these roles.
- Log onto Availity’s home page with your unique user ID and password
- Select Patient Registration
- Select Authorizations & Referrals
- Select Authorization Inquiry
- Choose the Payer and Organization
- Accept the ICR Disclaimer
- Select Check Case Status from the ICR navigation bar
What’s new?
The ICR Inquiry dashboard displays the new ICR Case Search tab. This new option is currently available for users who have the Authorization & Referral Request role. Users with the Authorization & Referral Inquiry role will be able to access the ICR Case Search tab in mid-July. Until then, the additional search options are available.
To locate a case submitted through ICR, select the ICR Case Search tab then choose the criteria to complete your search.
Use the additional search options to find cases submitted through both ICR and other sources.
Register for our monthly new user ICR webinar to learn about basic navigation and features. Or you can visit the Custom Learning Center located on Availity Payer Spaces to access ICR navigation demonstrations and reference guides.
Anthem uses Availity as our exclusive partner for managing all electronic data interchange (EDI) transactions.
When your organization’s claims are submitted either by your clearinghouse/vendor or submitted directly using practice management software, it’s important to review and utilize all responses to understand where your claims are in the adjudication process and if any action is required.
Below is a summary of the process for electronic files, and the response reports that are returned by Availity:
Electronic file is submitted to Availity
- Availity acknowledges receipt of file and validates for X12 format in a series of responses.
- The series of initial responses indicate whether an electronic file was successfully received in correct format and accepted by Availity.
- If errors occur, the impacted file will require resubmission to Availity.
- If your organization uses a clearinghouse/vendor, they are responsible for reviewing these response files.
HIPAA and business validation
- Electronic Batch Report (EBR) - This response acknowledges accepted claims and identifies claims with a HIPAA and business edits prior to routing for adjudication.
- Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice. (Edit examples include - Invalid subscriber ID for the date of service and invalid billing and coding per industry standards.)
- Clearinghouse/vendors may provide their own version of this report to your organization.
Availity routes claims to payer
- Delayed Payer Report (DPR) - This response file contains an additional level of editing by the membership adjudication system.
- Currently this response is returned only for Medicare/ Medicaid lines of business.
- Commercial lines of business will return this response in the future - look for forthcoming communications with the details.
- Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice.
- Clearinghouses/vendors may provide their own version of this report to your organization.
If you have further questions on the response reports, please contact Availity at 800-282-4548.
Like the payroll direct deposit service that most businesses offer their employees, electronic funds transfer (EFT) is a digital payment solution that uses the automated clearinghouse (ACH) network to transmit health care payments from a health plan to a health care provider’s bank account. Health plans can use a provider’s banking information only to deposit funds, not to withdraw funds.
Anthem expects providers to accept payment via EFT in lieu of paper checks. Providers can register or manage account changes for EFT via the CAQH enrollment tool called EnrollHub™. This tool will help eliminate the need for paper registration, reduce administrative time and costs and allows physicians and facilities to register with multiple payers at one time. By eliminating paper checks, EFT payments are deposited directly into your account faster.
Read more about going digital with Anthem in the Provider Digital Engagement Supplement available online. Go to anthem.com, select Providers, under the Provider Resources heading select Forms and Guides. Pick your state if you haven’t done so already. From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.
The following new and revised medical policies and clinical guidelines were endorsed at the May 13, 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
Revised medical policies effective May 20, 2021
The following policies were revised to expand medical necessity indications or criteria.
- OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
- 00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- 00143 - Perirectal Spacers for Use During Prostate Radiotherapy
- 00031 - Hematopoietic Stem Cell Transplant for Autoimmune Disease and Miscellaneous Solid Tumors
Reviewed medical policy effective July 1, 2021
The following medical policy was reviewed and updated with new procedure and/or diagnoses codes.
- 00098 - Hyperoxemic Reperfusion Therapy
Coding update effective July 1, 2021
The following policy was updated with new procedure and/or diagnosis codes.
- 00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
Revised medical policies effective July 7, 2021
The following policies were revised to expand medical necessity indications or criteria.
- 00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
- 00095 - Viscocanalosomy and Canaloplasty
Reviewed medical policies effective July 7, 2021
The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.
- 00002 - Preventive Health Guidelines
- 00004 - Medical Necessity Criteria
- 00005 - Investigational Criteria
- 00007 - Immunizations
- 00006 - Biomagnetic Therapy
- 00007 - Cosmetic and Reconstructive Services; Skin Related
- 00024 - Transtympanic Micropressure
- 00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
- 00037 - Cooling Devices and Combined Cooling/Heating Devices
- 00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
- 00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
- 00042 - Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
- 00010 - Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
- 00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
- 00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
- 00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
- 00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
- 00031 - Advanced Lipoprotein Testing
- 00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
- 00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
- 00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
- 00110 - Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications
- 00127 - Chelation Therapy
- 00131 - Electronic Home Visual Field Monitoring
- 00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
- 00133 - Ingestion Event Sensors
- OR-PR.00005 - Upper Extremity Myoelectric Orthoses
- OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
- 00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
- 00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
- 00005 - Partial Left Ventriculectomy
- 00007 - Vagus Nerve Stimulation
- 00010 - Treatments for Urinary Incontinence
- 00045 - Extracorporeal Shock Wave Therapy
- 00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- 00071 - Percutaneous and Endoscopic Spinal Surgery
- 00076 - Nerve Graft After Prostatectomy
- 00084 - Implantable Middle Ear Hearing Aids
- 00105 - Bicmpartmental Knee Arthroplasty
- 00111 - Axial Lumbar Interbody
- 00116 - High-Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
- 00118 - Bronchail Termoplasty
- 00120 - Internal Rib Fixation Systems
- 00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
- 00126 - Irreversible Electroporation
- 00134 - Interspinous Process Fixation Devices
- 00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- 00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
- 00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
- 00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
- THER-RAD.00012 - Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
- 00035 - Other Stem Cell Therapy
Archived medical policy effective July 7, 2021
The following medical policy has been archived and transitioned as an AIM Guideline.
- 00001 - Computed Tomography to Detect Coronary Artery Calcification
Archived medical policies effective July 7, 2021
The following medical policies have been archived and transitioned to a Clinical UM Guideline.
- 00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting (recategorized to CG-DME-48)
- 00034 - Standing Frames (recategorized to CG-DME-49)
Archived medical policies effective June 7, 2021
The following medical policies have been archived and transitioned to an existing Clinical UM Guideline.
- 00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome (combined into CG-GENE-13)
- 00046 - Prothrombin (Factor II) Mutation Testing (combined into CG-GENE-13)
Archived medical policy effective September 12, 2021
The following medical policy has been archived and it21s content was transitioned to either a Clinical UM Guideline or an AIM Guideline.
- 00127 - Sacroiliac Joint Fusion (Recategorize "open" to CG-SURG-111. Transition "min invasive" to AIM)
New medical policies effective October 1, 2021
The following policies are new and may result in services previously covered now being considered either not medically necessary and/or investigational.
- 00057 - Gene Expression Profiling for Idiopathic Pulmonary Fibrosis
- 00041 - Machine Learning Derived Probability Score for Rapid Kidney Function Decline
- 00137 - Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion
Revised medical policies effective October 1, 2021
The following policies listed below were revised and might result in services previously covered, but now being considered either not medically necessary and/or investigational.
- 00012 - Intrapulmonary Percussive Ventilation Devices
- 00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
- 00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
- 00155 - Cryoneurolysis
- 00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
Clinical guideline updates
Revised clinical guideline effective May 20, 2021
The following adopted guideline was revised to expand medical necessity indications or criteria.
- CG-SURG-27 - Gender Affirming Surgery
Revised clinical guideline effective July 1, 2021
The following adopted guideline was updated with new procedure and/or diagnoses codes.
- CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults
Archived clinical guideline effective July 7, 2021
The following adopted guideline has been archived.
- CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
Revised clinical guidelines effective July 7, 2021
The following adopted guidelines were revised to expand medical necessity indications or criteria.
- CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
- CG-GENE-13 - Genetic Testing for Inherited Diseases
- CG-SURG-12 - Penile Prosthesis Implantation
Reviewed clinical guidelines effective July 7, 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.
- CG-DME-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
- CG-DME-45 - Ultrasound Bone Growth Stimulation
- CG-DME-46 - Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
- CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
- CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)
- CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
- CG-MED-76 - Magnetic Source Imaging and Magneto-encephalography
- CG-MED-77 - SPECT/CT Fusion Imaging
- CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
- CG-SURG-05 - Maze Procedure
- CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
- CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-71 - Reduction Mammoplasty
- CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
- CG-SURG-84 - Mandibular/ Maxillary (Orthognathic) Surgery
- CG-SURG-85 - Hip Resurfacing
- CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
- CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
- CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
- CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus
- CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
Revised clinical guidelines effective October 1, 2021
The following adopted guidelines were revised and might result in services previously covered, but now being considered not medically necessary.
- CG-SURG-12 - Penile Prosthesis Implantation
- CG-SURG-27 - Gender Affirming Surgery
- CG-SURG-59 - Vena Cava Filters
New clinical guideline effective November 1, 2021
The following guideline is new and has been adopted.
- CG-MED-89 - Home Parenteral Nutrition
Beginning with dates of service on or after October 1, 2021, Anthem’s current Documentation and Reporting Guidelines for Consultations policy will be renamed Consultations. This policy aligns with CMS guidance and does not allow reimbursement for inpatient (99251-99255) or outpatient (99241-99245) consultation codes, and requires providers to bill the appropriate office visit Evaluation and Management (E/M) code for consultation services.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
Beginning with dates of service on or after October 1, 2021, we will implement a new reimbursement policy titled Non-Patient Laboratory Services. We do not allow reimbursement for non-patient laboratory services when reported on a UB-04 with bill type 014X unless provider, state, federal or CMS and/or requirements indicate otherwise.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
As part of our ongoing quality improvement efforts, we are updating our precertification processes for certain specialty medications. Effective August 2020, we may request additional documentation for impacted medications to determine medical necessity. See the list of impacted medications in the attached PDF.
Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.
Should you have any questions, please refer to our Clinical Criteria policy website for specific medication criteria details, including documentation requirements.
This is an update to the article published in the April 2021 issue of Provider News regarding Site of Care medical necessity reviews for long-acting colony-stimulating factors. The program will NOT be implemented on August 1, 2021. Medical necessity review of the site of care for the following long acting colony-stimulating factors for oncology indications will not be required beginning August 1, 2021, as originally communicated.
- Neulasta® & Neulasta Onpro® (pegfilgrastim)
- Fulphila® (pegfilgrastim-jmdb)
- Udenyca® (pegfilgrastim-cbqv)
- Ziextenzo® (pegfilgrastim-bmez)
- Nyvepria™ (pegfilgrastim-apgf)
There will be no changes for ordering providers who submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after August 1, 2021.
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the member’s ID card.
The following clinical criteria documents were endorsed at the May 21, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.
New clinical criteria effective June 5, 2021
The criteria below is new.
- ING-CC-0199: Empaveli (pegcetacoplan)
Revised clinical criteria effective June 21, 2021
The following criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0032: Botulinum Toxin
- ING-CC-0062: Tumor Necrosis Factor Antagonists
- ING-CC-0064: Interleukin-1 Inhibitors
- ING-CC-0066: Monoclonal Antibodies to Interleukin-6
- ING-CC-0098: Doxorubicin Hydrochloride Liposome
- ING-CC-0099: Abraxane (paclitaxel, protein bound)
- ING-CC-0107: Bevacizumab agents (Avastin, Mvasi)
- ING-CC-0111: Nplate (romiplostim)
- ING-CC-0120: Kyprolis (carfilzomib)
- ING-CC-0124: Keytruda (pembrolizumab)
- ING-CC-0127: Darzalex (daratumumab)
- ING-CC-0128: Tecentriq (atezolizumab)
- ING-CC-0142: Somatuline Depot (lanreotide)
- ING-CC-0150: Kymriah (tisagenlecleucel)
- ING-CC-0151: Yescarta (axicabtagene ciloleucel)
- ING-CC-0160: Vyepti (eptinezumab-jjmr)
- ING-CC-0161: Sarclisa (isatuximab-irfc)
- ING-CC-0163: Durysta (bimatoprost implant)
- ING-CC-0165: Trodelvy (sacituzumab govitecan)
Revised clinical criteria effective June 21, 2021
(The following criteria were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- ING-CC-0002: Colony Stimulating Factor Agents
- ING-CC-0045: Mecasermin (Increlex®)
- ING-CC-0057: Krystexxa (pegloticase)
- ING-CC-0061: GnRH Analogs for the Treatment of Non-Oncologic Indications
- ING-CC-0068: Growth hormone
- ING-CC-0069: Egrifta (tesamorelin)
- ING-CC-0087: Gamifant (emapalumab-lzsg)
- ING-CC-0092: Brentuximab Vedotin (Adcetris)
- ING-CC-0105: Vectibix (panitumumab)
- ING-CC-0106: Erbitux (cetuximab)
- ING-CC-0116: Bendamustine agents
- ING-CC-0134: Provenge (sipuleucel-T)
- ING-CC-0143: Polivy (polatuzumab vedotin-piiq)
- ING-CC-0153: Adakveo (crizanlizumab)
- ING-CC-0162: Tepezza (teprotumumab-trbw)
- ING-CC-0166: Trastuzumab Agents
- ING-CC-0171: Zepzelca (lurbinectedin)
- ING-CC-0175: Proleukin (aldesleukin)
- ING-CC-0178: Synribo (omacetaxine mepesuccinate)
- ING-CC-0183: Sogroya (somapacitan-beco)
- ING-CC-0192: Cosela (trilaciclib)
- ING-CC-0195: Abecma (idecabtagene vicleucel)
Revised clinical criteria effective July 1, 2021
The following criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0125: Opdivo (nivolumab)
Revised clinical criteria effective July 1, 2021
(The following criteria were updated with new procedure and/or diagnosis codes.)
- ING-CC-0061: GnRH Analogs for the Treatment of Non-Oncologic Indications
- ING-CC-0075: Rituximab Agents for Non-Oncology Indications
- ING-CC-0167: Rituximab Agents for Oncologic Indications Step Therapy
- ING-CC-0184: Danyelza (naxitamab-gqgk)
- ING-CC-0185: Oxlumo (lumasiran)
- ING-CC-0186: Margenza (margetuximab-cmkb)
- ING-CC-0187: Breyanzi (lisocabtagene maraleucel)
- ING-CC-0189: Amondys 45 (casimersen)
- ING-CC-0191: Pepaxto (melphalan flufenamide; melflufen)
- ING-CC-0192: Cosela (trilaciclib)
- ING-CC-0193: Evkeeza (evinacumab)
- ING-CC-0194: Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
New clinical criteria effective October 1, 2021
(The criteria below is new and may result in services previously covered now being considered either not medically necessary and/or investigational)
- ING-CC-0196: Zynlonta (loncastuximab tesirine-lpyl)
- ING-CC-0197: Jemperli (dostarlimab)
- ING-CC-0198: Relizorb (immobilized lipase) cartridge
Revised clinical criteria effective October 1, 2021
(The following criteria listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)
- ING-CC-0032: Botulinum Toxin
- ING-CC-0062: Tumor Necrosis Factor Antagonists
- ING-CC-0066: Monoclonal Antibodies to Interleukin-6
- ING-CC-0107: Bevacizumab agents (Avastin, Mvasi)
- ING-CC-0111: Nplate (romiplostim)
- ING-CC-0114: Jevtana (cabazitaxel)
- ING-CC-0124: Keytruda (pembrolizumab)
- ING-CC-0128: Tecentriq (atezolizumab)
- ING-CC-0137: Cablivi (caplacizumab-yhdp)
- ING-CC-0145: Libtayo (cemiplimab-rwlc)
- ING-CC-0160: Vyepti (eptinezumab-jjmr)
Prior authorization updates
Effective for dates of service on and after October 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Visit our website to access the clinical criteria information.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs 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).
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Clinical Criteria
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HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0195
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J3490, J9999, C9399, J3590
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Abecma
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* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Step therapy updates
Effective for dates of service on and after October 1,2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Visit our website to access the clinical criteria information.
Prior authorization clinical review of non-oncology 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).
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Clinical Criteria
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Status
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HCPCS or CPT Code
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Drug
|
|
ING-CC-0020
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Non-preferred
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J2323
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Tysabri
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CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.
The Clinical Data Acquisition Group for Anthem and AMH Health integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem and AMH Health:
- Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
- Proactively manage care transitions to avoid waste.
- Close care gaps and educate members about appropriate care settings.
Anthem and AMH Health would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem or AMH Health through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem and AMH Health to manage care transitions most effectively.
Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.
Help increase your vaccination rates and close gaps-in-care with these tools and strategies
Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.
Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:
- Address disparities for vaccine-preventable diseases.
- Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
- Access up-to-date vaccine guidance from the Centers for Disease Control and prevention (CDC).
- Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.
Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.
On October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Anthem and AMH Health, LLC. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
PA requirements will be added for the following codes:
- A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
- A0428 — ambulance service, basic life support, nonemergency transport (BLS)
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal or on our provider website. Contracted and noncontracted providers unable to access Availity can call the Provider Services located on the back of their patient’s member ID card for PA requirements.
On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for Anthem and AMH Health, LLC. These policies were developed, revised, or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of clinical criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The clinical criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
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Effective date
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Document number
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Clinical Criteria title
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New or revised
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|
July 16, 2021
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ING-CC-0195*
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Abecma (idecabtagene vicleucel)
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New
|
|
July 16, 2021
|
ING-CC-0191*
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Pepaxto (melphalan flufenamide; melflufen)
|
New
|
|
July 16, 2021
|
ING-CC-0192*
|
Cosela (trilaciclib)
|
New
|
|
July 16, 2021
|
ING-CC-0193*
|
Evkeeza (evinacumab)
|
New
|
|
July 16, 2021
|
ING-CC-0194*
|
Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
|
New
|
|
July 16, 2021
|
ING-CC-0125
|
Opdivo (nivolumab)
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Revised
|
|
July 16, 2021
|
ING-CC-0064
|
Interleukin-1 Inhibitors
|
Revised
|
|
July 16, 2021
|
ING-CC-0159*
|
Scenesse (afamelanotide)
|
Revised
|
|
July 16, 2021
|
ING-CC-0151
|
Yescarta (axicabtagene ciloleucel)
|
Revised
|
|
July 16, 2021
|
ING-CC-0145*
|
Libtayo (cemiplimab-rwlc)
|
Revised
|
|
July 16, 2021
|
ING-CC-0130*
|
Imfinzi (durvalumab)
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Revised
|
|
July 16, 2021
|
ING-CC-0127
|
Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
|
Revised
|
|
July 16, 2021
|
ING-CC-0075*
|
Rituximab Agents for Non-Oncologic Indications
|
Revised
|
Anthem and AMH Health, LLC, do not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate.
Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.
For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at www.anthem.com/medicareprovider.
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