 Provider News MaineMarch 2019 Anthem Maine Provider NewsletterHave you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You’ll now find these changes that were recently introduced:
- Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim.
- To send a solicited attachment, now find the ‘Send Attachment’ link on the top, right side of the page.
- Expanded file size – each attachment can now be up to 40 MB with a total of 80 MB as the file size limit.
If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.
How to access/setup the solicited medical attachments tool for your office
Availity Administrators must complete these steps:
- From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, follow the prompts and complete the following sections:
- Select Application > choose Medical Attachments Registration
- Provider Management > Select Organization from the drop-down. Add NPIs and/or tax IDs. (Multiples can be added separated by spaces or semi-colons.)
- Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name.
Submitting medical attachments
Once the above setup is completed, Availity Users will complete these steps:
- Log in to www.availity.com
- Select Claims and Payments > Attachments-New > Send Attachment Tab
- Complete all required fields of the form
- Attach supporting documentation
- Submit
Need training?
To access additional training for this Availity feature:
- Log in to the Availity Portal at www.availity.com
- At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
- In the new window a list of available topics will open. Locate and click Medical Attachments.
- Under the Recordings section, click View Recording
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research.
All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Practice Guidelines.
One of the measures we report on is Controlling High Blood Pressure (CBP). This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).
What’s new for 2019?
- The CBP measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
- If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
- Compliant BP is defined as <140/90 mm Hg for all members.
- Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the provider can be utilized for the measure.
What do we need from you?
We need the last two (2) office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018, please send that documentation as well.
Common chart deficiencies
- Recheck elevated blood pressures readings and document all BP readings in the medical record.
For more information on HEDIS visit anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Select Health & Wellness tab from the blue bar at the top of the page > Quality Improvement and Standards > HEDIS Information.
Thank you for your continued cooperation and support of HEDIS.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). We have designated Availity to operate and serve as your electronic data interchange (EDI) entry point, also called the EDI Gateway. The EDI Gateway is a no-cost option for providers that choose to submit their own EDI claims to us. If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.
As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.
Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.
- Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.
If you wish to become a direct a trading partner with Availity, the setup is easy.
Need assistance?
The Availity Quick Start Guide will assist you with any EDI connection questions you may have.
835 Electronic Remittance Advice (ERA)
Please use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes. Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.
Electronic Funds Transfer (EFT)
To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.
If you have any questions, contact Availity Client Services at 1-800-Availity (800-282-4548), Monday – Friday, 8:00 a.m. to 7:30 p.m. We continue to make it easier and more convenient to become an Anthem participating provider. The Digital Provider Enrollment application has been designed to speed up the enrollment process, allow providers to submit data at one time, and obtain real-time updates on the status of an application.
Access to the new application is available through Availity, our secure web-based provider portal.
New and current Availity users should ensure their user ID has the correct access. Please ensure that you have been assigned to Provider Enrollment.
Digital provider enrollment offers many benefits:
- Supports enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with us.
- New individual providers or groups can request a contract.
- Existing groups can add providers to their existing contract.
- Providers can check the status of an application in real-time using the enrollment dashboard.
To use the new Digital Enrollment application, please ensure your provider data on CAQH is current and in a complete or re-attested status, then log into Availity and use the following navigation: Choose your state > Payer Spaces > Provider Enrollment.
As a reminder, beginning with dates of service April 1, 2019, we will implement various hospital edits in support of the Place of Service and Evaluation and Management reimbursement policy and the Maine Statute MRSA 24-A, Chapter 18, §1912, Standardized Claim Forms, which addresses the claim form billing requirements for professional services.
Professional services affiliated with a hospital that are rendered on or off the hospital campus, including those rendered in the outpatient hospital setting, must be billed on the CMS 1500 claim form. Effective April 1, 2019, additional edits will be applied to the physical, occupational, and speech therapy (PT, OT, and ST) revenue codes (420 – 449). These services will no longer be allowed on the UB-04 claim form.
Medicare Advantage and Medicare Supplemental plans are excluded.
What do I need to do to be ready?
In preparation, hospitals whose professional PT, OT, ST providers are not already Anthem approved and credentialed should follow one of the steps below to begin the process of enrolling your professional providers:
- For enrollment of < 25 providers, complete the online New Provider Application for each individual provider; or
- For enrollment of > 25 providers, complete the Professional Roster Template.
Any questions regarding the enrollment process should be referred to Provider Service at 800-832-6011. Each year, we request your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented hierarchical condition categories (HCC), in order to document and close the coding gaps.
The CRA Program is specific to our Affordable Care Act (ACA) members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).
With our Retrospective Program we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS). This particular effort is part of our compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.
Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.
Anthem network providers, including PCPs, specialists, facilities, behavioral health, ancillary, etc., may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. The vendors’ web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management.
We ask that our network providers submit the medical record information to the designated vendor within 30 days of the request (no later than March 31, 2019). While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.
Electronic options that may make medical chart collection easier for providers:
- EMR Interoperability
- Allscripts (Opt in -- signature required)
- NextGen (Opt out -- auto-enrolled)
- Athenahealth (Opt out -- auto-enrolled)
- MEDENT
- Remote/direct Anthem access
- Vendor virtual or onsite visit
- Secure FTP
The goal of these electronic options is to both improve the medical record data extraction and the experience for our network-participating hospitals, clinics and physician offices. If you are interested in this type of set up or any other remote access options, please contact Alicia Estrada, our Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.
Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.
This March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms. A sample screen image of the upcoming changes is attached to this article.
This first version of the new Provider Forms will keep growing and evolving in the coming months.
We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes. Connecting with Anthem and staying informed is easy, fast and convenient with our provider eUpdates. eUpdates feature short topic summaries on late breaking news that impacts providers such as:
- Website updates
- System changes
- Policy updates
- Claims and billing updates
- And more…..
Registration is fast and easy. There is no limit to the number of subscribers who can register for our eUpdates, so your facility or practice can submit as many email addresses as you like. Sign up today! In January, Anthem, Inc. announced that it’s accelerating the launch of IngenioRx, its new pharmacy benefits manager (PBM), which will serve members of all Anthem’s affiliated health plans. We will begin moving some members to IngenioRx in Q2, and we will continue the transition, in waves, with the majority of members moving in the latter part of 2019 and Q1 2020.
As one of our contracted providers, we wanted to share a few details about what this means for you.
- If your patient has an active prior authorization it will transfer to IngenioRx.
- If your patient currently fills home delivery or specialty prescriptions through Express Scripts, prescriptions with at least one refill will be transferred, with the exception of controlled substances and compound drugs, to IngenioRx Home Delivery Pharmacy and IngenioRx Specialty Pharmacy.
- As your patients transition, new home delivery and specialty prescriptions will need to be sent to IngenioRx.
- For providers using ePrescribing there are no changes, simply select IngenioRx.
- For providers who do not use ePrescribing, you should send your home delivery and specialty prescriptions to IngenioRx.
IngenioRx Home Delivery Pharmacy new prescriptions: Phone Number: 833-203-1742 Fax number: 800-378-0323
IngenioRx Specialty Pharmacy: Prescriber phone: 833-262-1726 Prescriber fax: 833-263-2871
- If you want to check whether or not a specific patient has moved to IngenioRx, Availity will display the member’s PBM information under the patient information section as part of the eligibility and benefits inquiry.
- If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s ID card or call the number you normally use for questions.
For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions and other requirements, restrictions or limitations that apply to certain drugs, visit anthem.com/pharmacy information. The commercial and marketplace drug lists are reviewed and updates are posted to the website quarterly (the first of the month for January, April, July and October).
To locate the commercial drug list, visit anthem.com/pharmacy information, scroll down to Drug List Management and select 'Review our Commercial Drug Lists'.
To locate the Marketplace Select Formulary and pharmacy information, go to anthem.com/pharmacy information, scroll down to Drug List Management, select 'Review our Commercial Drug Lists', then scroll down to Select Drug Lists and select 'Maine Select Drug List'.
Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. Effective with dates of service on and after April 1, 2019, and in accordance with our Pharmacy and Therapeutic (P&T) process, we will update our commercial drug lists. Updates may include changes to drug tiers or the removal of a drug.
To help ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a preferred drug to patients currently using a non-preferred drug, if appropriate.
Please note, this update does not apply to the Select Drug List or drugs lists utilized by the Federal Employee Program (FEP).
To view a summary of changes, click here. On December 1, 2018, we introduced the new clinical criteria page for injectable, infused or implanted drugs. Effective for dates of service on and after March 1, 2019, the following new clinical criteria will be included in our clinical criteria review process. The drugs that require prior authorization will continue to require prior authorization notification with AIM.
Existing precertification requirements have not changed for the specific clinical criteria below. While there are no material changes, the document number and online location has changed. To access the clinical criteria information please click here. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical Guideline/Medical Policy.
Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Clinical Guideline/ Medical Policy
|
Clinical Criteria Document Number
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS or CPT Code(s)
|
CG-DRUG-29
|
ING-CC-0006
|
Hyaluronan Injections
|
Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synvisc/-One, TriVisc, Visco-3
|
J7318, J7320 , J7321, J7322, J7323, J7324 , J7325, J7326, J7327, J7328, J7329
|
DRUG.00015
|
ING-CC-0007
|
Synagis (palivizumab)
|
Synagis
|
90378
|
DRUG.00031
|
ING-CC-0008
|
Testopel (testosterone subcutaneous implant)
|
Testosterone implant
|
S0189
|
DRUG.00074
|
ING-CC-0009
|
Lemtrada (alemtuzumab)
|
Lemtrada
|
J0202
|
DRUG.00078
|
ING-CC-0010
|
Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
|
Praluent, Repatha
|
J3490 , J3590
|
DRUG.00095
|
ING-CC-0011
|
Ocrevus (ocrelizumab)
|
Ocrevus
|
J2350
|
DRUG.00099
|
ING-CC-0012
|
Brineura (cerliponase alfa)
|
Brineura
|
J0567
|
DRUG.00116
|
ING-CC-0013
|
Mepsevii (vestronidase alfa)
|
Mepsevii
|
J3490
|
CG-DRUG-03
|
ING-CC-0014
|
Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
|
Avonex, Plegridy, Rebif, Betaseron, Extavia, Copaxone, Glatopa
|
J1595, J1826, J1830, J3490, Q3027, Q3028
|
CG-DRUG-27
|
ING-CC-0017
|
Xiaflex (clostridial collagenase histolyticum) injection
|
Xiaflex
|
J0775
|
CG-DRUG-28
|
ING-CC-0018
|
Lumizyme (alglucosidase alfa)
|
Lumizyme
|
J0221
|
CG-DRUG-43
|
ING-CC-0020
|
Tysabri (natalizumab)
|
Tysabri
|
J2323
|
CG-DRUG-54
|
ING-CC-0021
|
Fabrazyme (agalsidase beta)
|
Fabrazyme
|
J0180
|
CG-DRUG-55
|
ING-CC-0022
|
Vimizim (elosulfase alfa)
|
Vimizim
|
J1322
|
CG-DRUG-56
|
ING-CC-0023
|
Naglazyme (galsulfase)
|
Naglazyme
|
J1458
|
CG-DRUG-57
|
ING-CC-0024
|
Elaprase (idursufase)
|
Elaprase
|
J1743
|
CG-DRUG-58
|
ING-CC-0025
|
Aldurazyme (laronidase)
|
Aldurazyme
|
J1931
|
CG-DRUG-73
|
ING-CC-0027
|
Denosumab agents
|
Prolia, Xgeva
|
J0897
|
CG-DRUG-84
|
ING-CC-0028
|
Benlysta (belimumab)
|
Benlysta
|
J0490
|
CG-DRUG-88
|
ING-CC-0029
|
Dupixent (dupilumab)
|
Dupixent
|
J3490, J3590
|
CG-DRUG-89
|
ING-CC-0030
|
Implantable and ER Buprenorphine Containing Agents
|
Probuphine, Sublocade
|
J0570, J3490 , Q9991, Q9992
|
CG-DRUG-103
|
ING-CC-0032
|
Botulinum Toxin
|
Botox, Xeomin, Dysport, Myobloc
|
J0585, J0586, J0587 , J0588 , J0585, J0586 , J0587 , J0588
|
CG-DRUG-104
|
ING-CC-0033
|
Xolair (omalizumab)
|
Xolair
|
J2357
|
CG-DRUG-108
|
ING-CC-0035
|
Duopa (carbidopa and levodopa enteral suspension)
|
Duopa
|
J7340
|
CG-DRUG-111
|
ING-CC-0037
|
Kanuma (sebelipase alfa)
|
Kanuma
|
J2840
|
CG-DRUG-112
|
ING-CC-0038
|
Human Parathyroid Hormone Agents
|
Tymlos
|
J3490
|
DRUG.00013
|
ING-CC-0039
|
GamaSTAN [(immune globulin (human)]
|
GamaSTAN. GamaSTAN S/D
|
J1460, J1560
|
DRUG.00027
|
ING-CC-0040
|
Prialt (ziconotide)
|
Prialt
|
J2278
|
DRUG.00050
|
ING-CC-0041
|
Soliris (eculizumab)
|
Soliris
|
J1300
|
DRUG.00077
|
ING-CC-0042
|
Monoclonal Antibodies to Interleukin-17
|
Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)
|
C9399, J3490, J3590
|
DRUG.00080
|
ING-CC-0043
|
Monoclonal Antibodies to Interleukin-5
|
Cinqair (reslizumba), Fasenra (benralizumab), Nucala (mepolizumab)
|
J0517, J2182, J2786
|
DRUG.00081
|
ING-CC-0044
|
Exondys 51 (eteplirsen)
|
Exondys 51
|
J1428
|
DRUG.00086
|
ING-CC-0045
|
Increlex (mecasermin)
|
Increlex
|
J2170
|
DRUG.00090
|
ING-CC-0046
|
Zinplava (bezlotoxumab)
|
Zinplava
|
J0565
|
DRUG.00096
|
ING-CC-0047
|
Trogarzo (ibalizumab-uiyk
|
Trogarzo
|
J1746
|
DRUG.00104
|
ING-CC-0048
|
Spinraza (nusinersen)
|
Spinraza
|
J2326
|
DRUG.00108
|
ING-CC-0049
|
Radicava (edaravone)
|
Radicava
|
J1301
|
DRUG.00111
|
ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
Ilumya, Tremfya
|
J1628, J3245
|
CG-DRUG-08
|
ING-CC-0051
|
Enzyme Replacement Therapy for Gaucher Disease
|
Cerezyme, Elelyso, Vpriv
|
J1786 , J3060 , J3385
|
CG-DRUG-44
|
ING-CC-0057
|
Krystexxa (pegloticase)
|
Krystexxa
|
J2507
|
CG-DRUG-45
|
ING-CC-0058
|
Octreotide Agents
|
Sandostatin, Sandostatin LAR Depot
|
J2353 , J2354
|
CG-DRUG-61
|
ING-CC-0061
|
GnRH Analogs for the treatment of non-oncologic indications
|
Zoladex, Supprelin LA, Lupron Depot/Depot-Ped, Lupaneta Pack, Synarel Nasal Spray, Triptodur
|
C9399, J3490, J1675, J1950, J3315, J3316, J9202 , J9217, J9218 , J9225, J9226 , J3490
|
CG-DRUG-69
|
ING-CC-0063
|
Stelara (ustekinumab)
|
Stelara
|
J3357, J3358
|
CG-DRUG-74
|
ING-CC-0064
|
Interleukin-1 Inhibitors
|
Arcalyst, Ilaris
|
J2793, J0638
|
CG-DRUG-93
|
ING-CC-0066
|
Monoclonal Antibodies to Interleukin-6
|
Actemra, Kevzara
|
J3262, C9399 , J3490 , J3590
|
CG-DRUG-82
|
ING-CC-0067
|
Prostacyclin Infusion and Inhalation Therapy
|
Flolan, Remodulin, Tyvaso, Veletri, Ventavis
|
J1325, J3285, J7686, K0455 , Q4074, S0155 , S9347
|
CG-DRUG-83
|
ING-CC-0068
|
Growth hormone
|
Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive
|
J2940 , J2941 , Q0515 , S9558
|
CG-DRUG-85
|
ING-CC-0069
|
Egrifta (tesamorelin)
|
Egrifta
|
J3490
|
CG-DRUG-86
|
ING-CC-0070
|
Jetrea (ocriplasmin)
|
Jetrea
|
J7316
|
CG-DRUG-87
|
ING-CC-0071
|
Entyvio (vedolizumab)
|
Entyvio
|
J2503 , C9257, J9035, Q5107 , J2778, J0178
|
CG-DRUG-92
|
ING-CC-0073
|
Alpha-1 Proteinase Inhibitor Therapy
|
Aralast, Glassia, Prolastin-C, Zemaira
|
J0256, J0257
|
CG-DRUG-94
|
ING-CC-0075
|
Rituxan (rituximab) for Non-Oncologic Indications
|
Rituxan
|
J9311
|
CG-DRUG-95
|
ING-CC-0076
|
Nulojix (belatacept)
|
Nulojix
|
J0485
|
CG-DRUG-105
|
ING-CC-0078
|
Orencia (abatacept)
|
Orencia
|
J0129
|
CG-DRUG-109
|
ING-CC-0079
|
Strensiq (asfotase alfa)
|
Strensiq
|
J3490
|
AIM Specialty Health® (AIM), a separate company, administers the specialty pharmacy clinical site of care program. Based on the information you provide, AIM will review the drug for both clinical appropriateness and the site of care against health plan clinical criteria when services are requested in the hospital outpatient facility setting. It is important to note that coverage for the site of care is documented within the approved pre-certification.
If you need to request a change to the site of care previously approved, please contact AIM at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m. View the Clinical Site of Care drug list and Clinical Site of Care pre-service clinical review FAQs for more information.
Effective January 1, 2019, the State of Maine Health Insurance Plan implemented a plan design change to incent members requiring hip and knee replacement and bariatric surgery procedures to receive those services at facilities designated as Centers of Excellence (COE). Member cost sharing for these procedures at designated facilities will be waived. Also, a travel benefit is being provided for members who need to travel more than 100 miles from their permanent residence to the COE.
To receive COE designation for these procedures, a hospital must have been awarded:
- Anthem’s Blue Distinction Plus designation, and
- An overall Leapfrog Safety Grade of “B” or better.
The following facilities in Maine have been designated as COEs.
Bariatric Facilities
- Maine Medical Center
- Central Maine Medical Center
- Eastern Maine Medical Center
Procedures
- Gastric banding
- Gastric stapling
Knee and Hip Facilities
- Maine Medical Center
- Central Maine Medical Center
- St. Joseph Hospital
Procedures
- Knee and hip replacements
- Total knee and hip replacements
- Revision knee and hip replacements
The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.
Clinical criteria effective date
|
Clinical criteria number
|
Clinical criteria
|
Clinical criteria (new/revised)
|
May 1, 2019
|
ING-CC-0001
|
Erythropoiesis Stimulating Agents
|
Revised
|
May 1, 2019
|
ING-CC-0004
|
H.P. Acthar Gel®
(repository corticotropin injection)
|
Revised
|
May 1, 2019
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
75743MUPENMUB 01/24/2019 Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.
This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.
Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.
If you have questions or feedback, please contact us. We updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:
- Group code patient responsibility (PR) will be assigned.
- Claim adjustment reason codes (CARCs) will include the following:
- 1 — deductible amount (professional claim)
- 2 — coinsurance amount (professional claim)
- 3 — copay amount (professional and facility claim)
- 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
- 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
- Remittance advice remark codes (RARCs) will include the following:
- N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
- N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
- N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.
Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.
75743MUPENMUB 01/24/2019 In 2019, we are offering dual eligible special needs plans (D-SNPs) to individuals who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs). D-SNPs provide enhanced benefits to individuals eligible for both Medicare and Medicaid. These plans are $0 premium plans. Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments. Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.
Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.
Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.
For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.
75743MUPENMUB 01/24/2019
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