Notices of material changes/amendments to contract may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements. In this issue, please reference the following articles:

• Medical Policy and Clinical Guideline updates
• Reimbursement policy update: Multiple and Bilateral Surgery Processing – Professional
• Specialty pharmacy updates
• Reimbursement policy update: Technology Assisted Surgical Procedures – Professional and Facility
• Clinical Criteria updates for specialty pharmacy
• Transition to Carelon Medical Benefits Management, Inc. MRI Breast Clinical Appropriateness Guidelines

Moving Toward Equity in Asthma Care
Anthem Blue Cross and Blue Shield is committed to achieving health equity in asthma outcomes with diverse populations. As part of this commitment, we offer an online training, Moving Toward Equity in Asthma Care. This course is accessible from any mobile device or computer and provides one continuing medical education credit at no cost to you. Visit www.mydiversepatients.com.

 Asthma Medication Ratio (AMR) HEDIS^® measure
The National Committee for Quality Assurance (NCQA) is also working to identify and reduce disparities in care. As part of this effort, race and ethnicity stratifications were added to the AMR HEDIS metric this year. The AMR metric measures the percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year.

 Did you know: 

• Hispanics and African Americans with asthma are less likely to take daily controllers and are more likely to visit the ER and be hospitalized for asthma-related conditions than non-Hispanic whites? ¹
• Asian Americans are more likely to die from asthma than non-Hispanic whites?²
• Appropriate medication management for patients with asthma could reduce the need for rescue medication — as well as the costs associated with ER visits, inpatient admissions, and missed days of work or school?

 Helpful tips:  

• Ensure at least half of the medications dispensed to treat asthma are controller medications throughout the measurement period. 
• Talk to the patient about the importance of controller medication compliance, and not to use rescue medications on a regular basis, unless part of asthma action plan.
• Encourage patients to fill their prescriptions on a regular schedule rather than waiting till they are symptomatic.
• Create a written asthma action plan in language the patient understands, and schedule follow-up appointments with patients. Ask patients questions to assess asthma control, adherence to the action plan, and identify
• Utilize evidence-based asthma assessment tools to assess asthma control, adherence to the action plan, and identify triggers.
• Take the Moving Toward Equity in Asthma Care CME course at no cost for more helpful tips.

Additional resources
Also available is the Asthma & Me training. Do your patients have asthma? Show them the pathophysiology of asthma in their preferred language.

References:

1. Asthma and Allergy Foundation of America & National Pharmaceutical Council. (2005). Ethnic Disparities in the Burden and Treatment of Asthma. Retrieved from http://www.aafa.org/media/Ethnic-Disparities-Burden-Treatment-Asthma-Report.pdf
2. U.S. Department of Health & Human Service, Office of Minority Health. (2016, May 9). Asthma and Asian Americans. Retrieved August 8, 2016, from https://www.minorityhealth.hhs.gov
3. Asthma and Allergy Foundation of America. (2020). Asthma Disparities in America: A Roadmap to Reducing Burden on Racial and Ethnic Minorities. Retrieved from: https://aafa.org/wp-content/uploads/2022/08/asthma-disparities-in-america-burden-on-racial-ethnic-minorities.pdf

We’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes.

Engagement Hub objectives:

• Learn strategies to help you and your care team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
• Offer care providers a convenient way to earn CME credits at a time that works best for you.

Register here for our free CME clinical quality webinars!

Note: Sessions in this series are approved for one American Academy of Family Physicians credit each.

Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/provider, then under Provider Overview, select Find Care.

Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:

• Add/change an address location
• Name change
• Provider leaving a group or a single location
• Phone/fax number changes
• Closing a practice location

Once you submit the form, we will send you an email acknowledging receipt of your request.

The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current.

Join this CME webinar to learn best practices to preventing falls of your older patients Wednesday, June 7, 2023 at noon EST.

Skilled Nursing Facility (SNF) providers: Fall prevention and patient safety

Providers can submit corrected claims for Federal Employee Program, (FEP), members using Availity Essentials* or through Electronic Data Interchange (EDI). The FEP member ID number start with the letter R, followed by eight numerical digits.

The corrected claims process begins when a claim has already been adjudicated. Multiple types of errors that occur can typically be corrected quickly with the options below. As a reminder, the corrected claim must be received within the timely filing.

Availity Essentials corrected claim submission

You can recreate a claim and submit it as a replacement or cancellation (void) of the original claim if Anthem has already accepted the original claim for processing. Follow these steps:

• In the Availity Essentials menu, select Claims & Payments, and then select Professional Claim or Facility Claim, depending on which type of claim you want to correct.
• Enter the claim information, and set the billing frequency and payer control number as follows:
  • Replacement of Prior Claim or Void/Cancel of Prior Claim.
  • Billing Frequency (or Frequency Type) field, in the Claim Information section (for professional and facility claims) or Ancillary Claim/Treatment Information section (for dental claims). Use 7 for replacement claims and 8 for voided claims.
  • Set the Payer Control Number (ICN / DCN) (or Payer Claim Control Number) field to the claim number assigned to the claim by Anthem. You can obtain this number from the 835 ERA or Remittance Inquiry on Payer Spaces.
• Submit the claim.

EDI corrected claim submission

Corrected claims submitted electronically must also have the applicable frequency code and payer control number.

Frequency code:

• For corrected professional (837P) claims, use one of the following frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
  • 7 — Replacement of prior claim\corrected claim
  • 8 — Void/cancel prior claim
• For corrected institutional (837I) claims, use bill type frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
  • 0XX7 — Replacement of prior claim
  • 0XX8 — Void/cancel prior claim

Payer claim control number:

• Use the original claim number assigned to the claim by Anthem.

Required EDI segments:

• CLM05-3: Frequency Code (7,8)
• REF: Payer Claim Control Number (original claim number)

Please confirm with your practice management software vendor and billing service or clearinghouse for full details and information on submitting corrected claims.

We encourage you and your staff to use the digital methods available to submit corrected claims to save costs in mailing, paper, and your valuable time.

For professional claims submitted on a CMS-1500 form processed on or after June 1, 2023, Anthem Blue Cross and Blue Shield will enhance our editing systems to automate edits and simplify remittance messaging. These edit enhancements are supported by correct coding guidelines as documented in industry sources such as Correct Procedural Terminology (CPT^®) guidelines and Centers for Medicare & Medicaid Services (CMS). Additionally, these edit enhancements will promote faster claim processing and reduce follow-up audits and/or record requests for claims that are not consistent with correct coding guidelines. As a result of these edit enhancements, there will be greater attention on identifying inappropriate billing of genetic testing services.

Below are examples of claim edits focused on identifying inappropriate billing of genetic testing services that will be automated:

• Multianalyte Assays with Algorithmic Analyses (MAAA) — CPT 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
• Panel testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists.
  Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual.

If you have questions on this program, contact your Provider Relationship Account Manager.

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. 

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines.

Notes/updates

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• CG-DME-31 - Powered Wheeled Mobility Devices:
  • Added Not Medically Necessary statement for powered wheeled mobility devices using computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain (for example, the iBOT Personal Mobility Device) for all indications
• CG-LAB-24 - Outpatient Urine Culture:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for outpatient urine culture testing for bacteria
• CG-LAB-25 - Outpatient Glycated Hemoglobin and Protein Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for outpatient glycated hemoglobin (HbA1c) and total glycated serum proteins (GSPs) testing
• CG-MED-92 - Foot Care Services:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for foot care services
• CG-MED-93 - Navigational Bronchoscopy:
  • Moved content from MED.00099 Navigational Bronchoscopy to a new clinical UM guideline document with the same title
  • Added Medically Necessary criteria for navigational bronchoscopy
  • Revised Investigational & Not Medically Necessary statement to Not Medically Necessary when criteria not met
• CG-SURG-115 - Mechanical Embolectomy for Treatment of Stroke:
  • Moved content from SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke to new clinical UM guideline document with a similar title
  • Investigational & Not Medically Necessary changed to Not Medically Necessary as a result of MP to CUMG transition
• CG-SURG-116 - Surgical Treatment of Hyperhidrosis:
  • Moved content from CG-MED-63 Treatment of Hyperhidrosis to new clinical UM guideline document
  • Change of category and addition of surgical to title
  • Moved content related to iontophoresis to CG-MED-28 Iontophoresis
• GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
  • Moved content from GENE.00037 Genetic Testing for Macular Degeneration and CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions into this document
  • Added chromosome conformation signatures to scope of document and Investigational & Not Medically Necessary statement
• MED.00130 - Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring; Previously titled: Surface Electromyography Devices for Seizure Monitoring:
  • Revised title
  • Revised Position Statement by adding electrodermal activity sensor devices
• MED.00135 - Gene Therapy for Hemophilia:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for a one-time infusion of etranacogene dezaparvovec-drlb for select individuals with hemophilia B
• MED.00143 - Ingestible Devices for the Treatment of Constipation:
  • Outlines the Investigational & Not Medically Necessary criteria for Ingestible devices for the treatment of constipation
• SURG.00097 - Scoliosis Surgery:
  • Added magnetically controlled growing rods to scope of document in Investigational & Not Medically Necessary statement

Medical Policies

On November 10, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to AMH Health, LLC. These guidelines take effect April 30, 2023.

Clinical UM Guidelines

On November 10, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to AMH Health. These guidelines were adopted by the medical operations committee for AMH Health members on December 15, 2022. These guidelines take effect April 30, 2023.

The fax number on the previous communication was incorrect and has been corrected here. The correct fax number is 833-678-0223.

For services beginning on July 1, 2023, prior authorization requests for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services will be reviewed by Carelon Post Acute Solutions, LLC.* The goal of this program is to ensure members receive the right product for the right duration of time in the home. This change will be applicable to the following markets: Maine.

How to submit or check a prior authorization request

For DMEPOS services, Carelon Post Acute Solutions will begin receiving requests on Tuesday, June 20, 2023, for dates of service July 1, 2023, and after.  

Providers are encouraged to request authorization using the website. Go here to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions at 833-678-0223.

Please note: Carelon Post Acute Solutions will not review authorization requests for products/services that do not fall under Medicare-covered products/services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit the website or email.

If you have additional questions, please call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622.

Join this CME webinar to learn best practices to preventing falls of your older patients Wednesday, June 7, 2023 at noon EST.

Skilled Nursing Facility (SNF) providers: Fall prevention and patient safety

We’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes.

Engagement Hub objectives:

• Learn strategies to help you and your care team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
• Offer care providers a convenient way to earn CME credits at a time that works best for you.

Register here for our free CME clinical quality webinars!

Note: Sessions in this series are approved for one American Academy of Family Physicians credit each.

Who is affected

For women ages 67 to 85 who sustained a recent fracture, it is important to obtain a bone density scan to assess for osteoporosis.

How can we collaborate?

We can help your patients complete this scan in the comfort of their home through Quest Health Connect.

In home resources

We are working with Quest HealthConnect™, a Quest Diagnostics service, to provide this service at no added cost to you. Quest HealthConnect will call your patient to arrange a visit. Patients may also call them directly at 888-306-0615 between 8:30 a.m. to 4 p.m. Eastern Time. The result(s) of the screening test(s) will be sent to both the patient and your office after the visit.