March 2019 Anthem Maine Provider Newsletter

Contents

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Explore updates to medical attachment tool

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical practice and preventive health guidelines available on anthem.com

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

HEDIS® 2019: Controlling High Blood Pressure

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

EDI Gateway migration updates

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Digital Provider Enrollment application now available

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Outpatient/office physical, speech, and occupational therapy claim form requirements

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Commercial Risk Adjustment Program update: Medical chart collection for ACA members due March 31, 2019

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Additional changes to anthem.com to launch in March

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Sign up today for provider eUpdates

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Some of your patients will begin moving to IngenioRx in Q2 2019

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Pharmacy information available on anthem.com

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Commercial drug list important updates

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Specialty pharmacy clinical site of care program important reminder

State Health Benefit PlanAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

State of Maine Health Insurance Plan incents members to seek bariatric and hip/knee procedures at Centers of Excellence

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Keep up with Medicare news

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Clinical criteria updates for specialty pharmacy

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Introducing a new clinical criteria web page for injectable, infused or implanted drugs covered under the medical benefit

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Change to 835 ERA for all D-SNP MA members for 2019

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Dual eligible special needs plans: provider training required

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Explore updates to medical attachment tool

Have 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:

  1. From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, follow the prompts and complete the following sections:
  2. Select Application > choose Medical Attachments Registration
  3. Provider Management > Select Organization from the drop-down. Add NPIs and/or tax IDs. (Multiples can be added separated by spaces or semi-colons.)
  4. 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:

  1. Log in to www.availity.com
  2. Select Claims and Payments > Attachments-New > Send Attachment Tab
  3. Complete all required fields of the form
  4. Attach supporting documentation
  5. Submit

               

Need training?

To access additional training for this Availity feature:

  1. Log in to the Availity Portal at www.availity.com
  2. 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.)
  3. In the new window a list of available topics will open. Locate and click Medical Attachments.
  4. Under the Recordings section, click View Recording

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical practice and preventive health guidelines available on anthem.com

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.

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

HEDIS® 2019: Controlling High Blood Pressure

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).

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

EDI Gateway migration updates

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.

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Digital Provider Enrollment application now available

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.

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Outpatient/office physical, speech, and occupational therapy claim form requirements

 

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:

  1. For enrollment of < 25 providers, complete the online New Provider Application for each individual provider; or
  2. 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.

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Commercial Risk Adjustment Program update: Medical chart collection for ACA members due March 31, 2019

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.  

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Additional changes to anthem.com to launch in March

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.

ATTACHMENTS (available on web): Provider Forms and Guidelines.jpg (jpg - 0.13mb)

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Sign up today for provider eUpdates

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!

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Some of your patients will begin moving to IngenioRx in Q2 2019

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.

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Pharmacy information available on anthem.com

For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions 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.

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Commercial drug list important updates

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.

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy

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

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Specialty pharmacy clinical site of care program important reminder

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.

 

State Health Benefit PlanAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

State of Maine Health Insurance Plan incents members to seek bariatric and hip/knee procedures at Centers of Excellence

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:

  1. Anthem’s Blue Distinction Plus designation, and
  2. 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

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Keep up with Medicare news

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Clinical criteria updates for specialty pharmacy

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

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Introducing a new clinical criteria web page for injectable, infused or implanted drugs covered under the medical benefit

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.

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Change to 835 ERA for all D-SNP MA members for 2019

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

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Dual eligible special needs plans: provider training required

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