 Provider News MaineNovember 2019 Anthem Maine Provider NewsMore exciting new changes are coming to the public provider site at anthem.com. This next wave of updates includes a new, enhanced Medical Policies page. The page will have an improved and straightforward process for viewing policies that allows providers to easily scan, sort and filter. In addition, providers will now be able to access “Search” from the Medical Policies landing page. Below is a preview of the streamlined page:
As we communicated in the October 2019 edition of Provider News, the AIM Rehabilitative program for our Commercial membership will relaunch on November 1. AIM Specialty Health® (AIM), a separate company, will begin to perform prior authorization review of physical, occupational and speech therapy services. Prior authorization requests may be submitted via the AIM ProviderPortalSM for dates of service November 1, 2019 and after. The OrthoNet program is no longer active in applicable markets.
Anthem is also transitioning vendors for review of outpatient physical, occupational and speech therapy rehabilitative services for our Medicare members to AIM Specialty Health. We have decided to delay the implementation of this transition. The AIM Rehabilitative program for Medicare members will now begin in April 2020. Prior authorization will not be required for the above-mentioned services for Medicare members through March 2020. (Note: This delay does NOT apply to members in the states of Florida, New Jersey and New York for whom prior authorization will still be required.) We will provide an update in an upcoming Provider News about the AIM Rehabilitative Program for Medicare members. As the physician of members who have coverage under an Affordable Care Act (ACA) compliant plans, you play a vital role in accurately documenting the health of members to ensure compliance with ACA program reporting requirements. When members visit your practice, we encourage you to document ALL of the members’ health conditions, especially chronic diseases. Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.
Please ensure that all codes captured in your EMR system are also included on the claim(s), and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing 4. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.
Reminder about ICD-10 coding
As you may be aware, the ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, we use ICD-10 codes submitted on claims to monitor health care trends and costs, disease management, and clinical effectiveness of management of medical conditions. The Centers for Medicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a member’s health.
Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.
- Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
- Include any secondary diagnosis codes that are actively being managed.
- Include all chronic historical codes, as they must be documented each year pursuant to the ACA. (E.g.: An amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).
If you are interested in having a coding training session conducted by an Anthem coding auditor, please contact our Commercial Risk Adjustment Representative who supports your area: Alicia.Estrada@anthem.com. Category: Medicare
As we implement additional correct coding guideline edits this fall, we want to highlight some important reminders regarding our expectations concerning modifier use. We understand that the billing of patient treatment has some important nuances that make billing complex at times. This article is one of several you’ll find in upcoming newsletters.
Things to remember
- Review the “CPT Surgical Package Definition” found in the current year’s CPT Professional Edition. Use modifiers such as 25 and 59 only when the services are not included in the surgical package.
- Review, the current year’s CPT Professional Edition Appendix A - Modifiers. Pay attention to the appropriate use of modifiers 25, 57 and 59
- Use modifier 25 with evaluation and management codes. Modifier 25 should be used when performing E/M services “above and beyond” or “separate and significant” from any procedures performed the same day.
- Review Level II HCPCS modifiers. When appropriate, assign anatomical modifiers to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim.
- Use modifier 59 to indicate that a procedure or service was distinct or independent of other “non E/M services” performed on the same date of service. The modifier 59, represents services not normally performed together but may be reported together under the circumstances.
If you feel that you have received an inappropriate denial after applying a modifier appropriately, please follow the normal claims dispute process and include medical records that support the usage of the modifiers when submitting claims for consideration. The following new and revised medical policies were endorsed at the August 22, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > select state > scroll down and select Review Policies > then select View Medical Policies & UM Guidelines.
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies.
Revised medical policies effective August 29, 2019
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00082 - Daratumumab (DARZALEX®)
- OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
- RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
Transitioned medical policy effective September 1, 2019
(The following policy has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)
DRUG.00082 - Daratumumab (DARZALEX®) [Transitioned to ING-CC-0127]
Revised medical policy effective September 25, 2019
(The following policy was revised to expand medical necessity indications or criteria.)
- GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
Revised medical policies effective September 25, 2019
(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- ADMIN.000006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
- BEH.00002 - Transcranial Magnetic Stimulation
- DME.00011 - Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
- DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
- GENE.00010 - Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
- GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
- GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
- GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
- GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies
- GENE.00047 - Methylenetetra-hydrofolate Reductase Mutation Testing
- LAB.00019 - Serum Markers for Liver Fibrosis in the Evalution and Monitoring of Patients with Chronic Liver Disease
- LAB.00028 - Serum Biomarkers for Multiple Sclerosis
- LAB.00029 - Rupture of Membranes Testing in Pregnancy
- LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
- MED.00055 - Wearable Cardioverter Defibrillators
- MED.00082 - Quantitative Sensory Testing
- MED.00085 - Antineoplaston Therapy
- MED.00089 - Quantitative Muscle Testing Devices
- MED.00095 - Anterior Segment Optical Coherence Tomography
- MED.00096 - Low-Frequency Ultrasound Therapy for Wound Management
- MED.00099 - Electromagnetic Navigational Bronchoscopy
- MED.00103 - Automated Evacuation of Meibomian Gland
- OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
- RAD.00037 - Whole Body Computed Tomography Scanning
- RAD.00057 - Near-Infrared Coronary Imaging and Near- Infrared Intravascular Ultrasound Coronary Imaging
- RAD.00061 - PET/MRI
- RAD.00062 - Intravascular Optical Coherence Tomography (OCT)
- RAD.00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
- SURG.00008 - Mechanized Spinal Distraction Therapy
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
- SURG.00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
- SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
- SURG.00092 - Implanted Devices for Spinal Stenosis
- SURG.00095 - Viscocnalosomy and Canaloplasty
- SURG.00101 - Suprachoroidal Injection of a Pharmocoligc Agent
- SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
- SURG.00114 - Facet Joint Allograft Implants for Facet Disease
- SURG.00119 - Endobronchial Valve Devices
- SURG.00127 - Sacroiliac Joint Fusion
- SURG.00128 - Implantable Left Atrial Hemodynamic Monitor
- SURG.00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
- SURG.00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
- SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
- TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease
Archived medical policies effective September 25, 2019
(The following policies have been archived.)
- MED.00041 - Microvolt T-Wave Alternans
- RAD.00040 - PET Scanning using Gamma Cameras
Revised medical policies effective October 1, 2019
(The following policies were updated with new procedure and/or diagnosis codes.)
- GENE.00001 - Genetic Testing for Cancer Susceptibility
- GENE.00009 - Gene-Based Tests for Screening, Detection or Management of Prostate Cancer
- GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
- GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
- LAB.00011 - Analysis of Proteomic Patterns
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
- SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
- TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
- TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- TRANS.00028 - Hematopoietic Stem Cell Transplant for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
- TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
- TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
- TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
Archived medical policy effective November 12, 2019
(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)
- GENE.00044 - Analysis of PIK3CA Status in Tumor Cells [Content transferred to CG-GENE-12]
Archived medical policy effective November 12, 2019
(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)
- RAD.00004 - Peripheral Bone Mineral Density Measurement [Content transferred to CGMED-39]
New medical policy effective February 1, 2020
(The policy below is new and may result in services previously covered, but now being considered either not medically necessary and/or investigational)
- MED.00130 - Surface Electromyography Devices for Seizure Monitoring
Revised medical policies effective February 1, 2020
(The following policies listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
- GENE.00046 - Prothrombin (Factor II) Genetic Testing
- MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, and Soft Tissue Grafting, and Regenerative Therapy
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- TRANS.00035 - Non-Hematopoietic Adult Stem Cell Therapy
The following new and revised medical policies were endorsed at the August 22, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > select state > scroll down and select Review Policies > then select View Medical Policies & UM Guidelines.
If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Revised clinical guideline effective September 25, 2019
(The following guideline was revised to expand medical necessity indications or criteria.)
CG-MED-68 - Therapeutic Apheresis
Revised clinical guidelines effective September 25, 2019
(The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use
CG-DME-44 - Electric Tumor Treatment Field (TTF)
CG-GENE-03 - BRAF Mutation Analysis
CG-MED-63 - Treatment of Hyperhidrosis
CG-MED-65 - Manipulation under Anesthesia
CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
CG-REHAB-04 - Physical Therapy
CG-REHAB-05 - Occupational Therapy
CG-REHAB-06 - Speech-Language Pathology Services
CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services
CG-REHAB-08 - Private Duty Nursing
CG-SURG-28 - Transcatheter Uterine Artery Embolization
CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
CG-SURG-59 - Vena Cava Filters
CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
CG-SURG-79 - Implantable Infusion Pumps
Revised clinical guidelines effective October 1, 2019
(The following guidelines were updated with new procedure and/or diagnosis codes.)
CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
CG-SURG-09 - Temporomandibular Disorders
CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
CG-SURG-97 - Cardioverter Defibrillators
Adopted clinical guideline effective November 12, 2019
(The following guideline was previously a medical policy and has been adopted with no significant changes.)
CG-GENE-12 - PIK3CA Mutation Testing [previously GENE.00044]
Unadopted clinical guidelines effective November 12, 2019
(The criteria in the following guidelines will no longer be applied to any member claims.)
CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies [Combined with CG-SURG-80 and CG-THER-RAD-04]
CG-MED-39 - Bone Mineral Density Testing Measurement [combined with RAD.00004]
Archived clinical guidelines effective November 20, 2019
(The following adopted clinical guidelines have been archived and its content has been transferred to existing Clinical UM Guidelines.)
CG-SURG-80: Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors [Content transitioned to CG-SURG-78]
CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors [Content transitioned to CG-SURG-78]
Revised clinical guidelines effective February 1, 2020
(The following guidelines listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)
CG-ANC-07 - Inpatient Interfacility Transfers
CG-GENE-02 - Analysis of RAS Status
CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Advanced Imaging of the Abdomen and Pelvis Clinical Appropriateness Guidelines.
- Foreign body (pediatric only), gastrointestinal bleeding, Henoch-Schonlein purpura, hematoma or hemorrhage – intracranial or extracranial, perianal fistula/abscess (fistula in ano), ascites, biliary tract dilatation or obstruction, cholecystitis, choledocholithiasis, focal liver lesion, hepatomegaly, jaundice, azotemia, adrenal mass, indeterminate, hematuria, renal mass, urinary tract calculi, adrenal hemorrhage, adrenal mass, lymphadenopathy, splenic hematoma, undescended testicle (cryptorchidism)
- Abdominal and/or pelvic pain
- Combined pelvic pain with abdominal pain criteria in new “abdominal and/or pelvic pain” indication
- Required ultrasound or colonoscopy for select adult patients based on clinical scenario
- Ultrasound-first approach for pediatric abdominal and pelvic pain
- Lower extremity edema
- Added requirement to exclude DVT prior to abdominopelvic imaging
- Splenic mass, benign, splenic mass, indeterminate, splenomegaly
- Added new indications for diagnosis, management, and surveillance of splenic incidentalomas following the ACR White Paper (previously reviewed against “tumor, not otherwise specified”)
- Pancreatic mass
- Separated criteria for solid and cystic pancreatic masses
- Defined follow up intervals for cystic pancreatic masses
- Diffuse liver disease
- Added criteria for MR elastography
- Inflammatory bowel disease
- Limited requirement for upper endoscopy to patients with relevant symptoms
- New requirement for fecal calprotectin or CRP to differentiate IBS from IBD
- Enteritis or colitis, not otherwise specified
- Incorporated Intussusception (pediatric only), and ischemic bowel
- Prostate cancer
- Moved this indication to Oncologic Imaging Guideline
- CPT codes
- Added MR elastography CPT code 76391
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Radiation Therapy Clinical Appropriateness Guidelines.
- Special treatment procedure and special physics consult
- Removed oral cone endocavitary indication
- Intensity modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT) for bone metastases
- Broadened description of adjacent normal tissues which may be of concern
- Single fraction treatment
- Removed poor performance status criteria
- Central nervous system cancers
- Spine lesions; primary or metastatic lesions of the spine, metastatic lesions in the lung
- Added note calling out separate criteria for curative intent treatment of extracranial oligometastatic disease.
- SBRT in the treatment of extracranial oligometastatic disease
- Added new section with discussion and indications
- Prostate cancer – hypofractionation
- Added fractionation guideline with EBRT/IMRT
- Prostate cancer – postoperative radiotherapy and SBRT
- Added indication based on ASTRO/ASCO/AUA recommendation
- Prostate cancer – use of hydrogel spacer
- Added discussion and medical necessity statement about hydrogel spacers for prostate irradiation
- CPT code changes
- Added 77316, 77295 and 55874
- Removed 77427
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Musculoskeletal Program Spine Surgery Clinical Appropriateness Guidelines.
- Conservative management – all sections
- Addition of physical therapy or home therapy requirement and one complementary modality for all spine procedures based on preponderance of benefit over harm to conservative care
- Lumbar disc arthroplasty
- Changed the duration of conservative management from 1 year to 6 months based on the FDA prospective study that was done to approve the lumbar disc arthroplasty procedure
- Added age, level requirements, and symptom/sign requirement and clarified contraindications in reflect these changes
- Added exclusions criteria of Prior spine surgery of any form at the target level
- Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)
- Inclusion for implant failure similar to cervical spine
- Consolidated juvenile and congenital in adolescent idiopathic
- Decreased duration of conservative management required based on lower evidence for efficacy in spinal stenosis and specialty panel feedback
- Excluded anterior lumbar interbody fusion for foraminal stenosis without evidence of instability exclusion due to very low quality evidence for efficacy
- Lumbar laminectomy
- Decreased duration of conservative care required for known spinal stenosis based on guidance from NASS and less evidence for efficacy of conservative management in this population
- Aligned conservative care duration with discectomy criteria
- Added new indication for synovial cyst
- Noninvasive electrical bone growth stimulation
- Clarification of guideline intent
- Allow active nicotine use as a risk factor in lumbar uses of bone growth stimulation
- Allow thoracic fusion similar to lumbar
- Bone graft substitutes and bone morphogenetic proteins
- Allow active nicotine use as a risk factor for pseudoarthrosis in graft failure
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guidelines.
- Polysomnography and home sleep testing: established sleep disorder (OSA or other) – follow-up laboratory studies
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
- Management of OSA using APAP and CPAP Devices
- Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. The launch of our new pharmacy benefits manager (PBM) solution, IngenioRx, is nearly complete. IngenioRx serves members of all Anthem-affiliated health plans. We began transitioning members on May 1, 2019, continuing throughout 2019, with all members completely transitioned to IngenioRx by January 1, 2020.
As a reminder, most day-to-day pharmacy experiences will not be affected:
- Members will continue to use their prescription drug benefits as they always have, getting their medications using a retail pharmacy, home delivery or specialty pharmacy.
- Current home delivery and specialty pharmacy prescriptions and prior authorizations will transfer automatically to IngenioRx when a member transitions, with the exception of controlled substances and compound drugs (see more below).
- If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx after your patient has transitioned.
- If you do not use ePrescribing, send home delivery and specialty pharmacy prescriptions to IngenioRx after your patient has transitioned (see contact information below).
- Members will continue to use the same drug list.
Frequently Asked Questions
Q. When can I expect my patients to transition to IngenioRx?
A. Most Anthem members have already transitioned to IngenioRx. The remaining members will be transitioned on January 1, 2020.
Q. Do providers need to take any action?
A. Federal law does not allow prescriptions for controlled substances or compound drugs to be automatically transferred to another pharmacy, so providers with patients using these medications will need to send a new prescription to IngenioRx after they’ve transitioned.
Q. Will my patients be notified of this change?
A. Anthem will notify members before they transition to IngenioRx. Members currently filling home delivery and specialty pharmacy medications will be notified by mail.
Q. How will a provider know if an Anthem member has moved to IngenioRx?
A. Availity displays member PBM information under the patient information section as part of the eligibility and benefits inquiry. We have enhanced this section of Availity to indicate when a member has moved to IngenioRx. Availity includes the name of the PBM and date the member moved to IngenioRx, or the date the member is scheduled to move to IngenioRx.
Q. How will specialty drugs be transitioned?
A. Specialty pharmacy prescriptions and prior authorizations will automatically transfer to IngenioRx. In addition, the IngenioRx Care Team will call members to introduce them to IngenioRx and discuss the medications they take.
Q. How do I submit prescriptions to IngenioRx?
A. If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx in your ePrescribing system. If you do not use ePrescribing, you can submit prescriptions using the following information:
IngenioRx Home Delivery Pharmacy new prescriptions:
Phone: 833-203-1742
Fax: 800-378-0323
IngenioRx Specialty Pharmacy:
Prescriber phone: 833-262-1726
Prescriber fax: 833-263-2871
Q. What phone number should I call with questions?
A. For questions, contact the Provider Service phone number on the back of the member's ID card.
Pre-service clinical review updates
Effective for dates of service on and after February 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our pre-service review process.
Please note, inclusion of the NDC code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
To access the clinical criteria document information please click here.
Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company, and are in italics.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0072
|
Q5118
|
Zirabev
|
|
ING-CC-0075
|
Q5115
|
Truxima
|
|
ING-CC-0075
|
J3490
|
Ruxience
|
|
ING-CC-0107
|
Q5118
|
Zirabev
|
|
*ING-CC-0142
|
J1930
|
Somatuline Depot
|
|
ING-CC-0143
|
C9399, J9999
|
Polivy
|
|
ING-CC-0144
|
J9313
|
Lumoxiti
|
|
ING-CC-0145
|
J9119
|
Libtayo
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team; oncology use is managed by AIM.
Quantity limit updates
Effective January 31, 2020, clinical criteria document ING-CC-0136 drug dosage, frequency, and route of administration will be archived.
Effective for dates of service on and after February 1, 2020, pre-service clinical review of drug dosage, frequency and route of administration for the following specialty pharmacy codes from new or current clinical criteria will be based on the quantity limits established in the applicable clinical criteria document. The table below will assist you in identifying the applicable clinical criteria documents and corresponding HCPCS codes.
To access the clinical criteria document information please click here.
Pre-service clinical review of these specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.
|
Clinical Criteria Number
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS Code(s)
|
|
ING-CC-0001
|
Erythropoiesis Stimulating Agents
|
Aranesp, Epogen, Mircera, Procrit, Retacrit
|
J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106
|
|
ING-CC-0003
|
Immunoglobulins
|
Asceniv, Bivigam, Carimune NF, Flebogamma DIF, Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen
|
J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
|
|
ING-CC-0007
|
Synagis (palivizumab)
|
Synagis
|
90378
|
|
ING-CC-0013
|
Mepsevii (vestronidase alfa)
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Mepsevii
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J3397
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|
ING-CC-0018
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Lumizyme (alglucosidase alfa)
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Lumizyme
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J0221
|
|
ING-CC-0021
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Fabrazyme (agalsidase beta)
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Fabrazyme
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J0180
|
|
ING-CC-0022
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Vimizim (elosulfase alfa)
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Vimizim
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J1322
|
|
ING-CC-0023
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Naglazyme (galsulfase)
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Naglazyme
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J1458
|
|
ING-CC-0024
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Elaprase (idursufase)
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Elaprase
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J1743
|
|
ING-CC-0025
|
Aldurazyme (laronidase)
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Aldurazyme
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J1931
|
|
ING-CC-0028
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Benlysta (belimumab)
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Benlysta
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J0490
|
|
ING-CC-0031
|
Intravitreal Corticosteroid Implants
|
Illuvien, Retisert, Ozurdex, Yutiq
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J7311, J7312, J7313, J7314
|
|
ING-CC-0032
|
Botulinum Toxin
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Botox, Xeomin, Dysport, Myobloc
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J0585, J0586, J0587, J0588
|
|
ING-CC-0033
|
Xolair (omalizumab)
|
Xolair
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J2357
|
|
ING-CC-0034
|
Agents for Hereditary Angioedema
|
Cinryze, Haegarda, Berinert, Berinert, Firazyr, Ruconest, Kalbitor, Takhzyro
|
J0596, J0597, J0598, J1290, J1744, J0599, J0593
|
|
ING-CC-0041
|
Complement Inhibitors
|
Soliris, Ultomiris
|
J1300, J1303
|
|
ING-CC-0043
|
Monoclonal Antibodies to Interleukin-5
|
Cinqair, Fasenra, Nucala
|
J0517, J2182, J2786
|
|
ING-CC-0050
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Monoclonal Antibodies to Interleukin-23
|
Tremfya, Ilumya
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J1628, J3245
|
|
ING-CC-0051
|
Enzyme Replacement Therapy for Gaucher Disease
|
Cerezyme, Elelyso, Vpriv
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J1786, J3060, J3385
|
|
ING-CC-0058
|
Octreotide Agents
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Sandostatin, Sandostatin LAR Depot
|
J2353, J2354
|
|
ING-CC-0061
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GnRH Analogs for the treatment of non-oncologic indications
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Lupron Depot/Depot-Ped
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J1950, J9217
|
|
ING-CC-0062
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Tumor Necrosis Factor Antagonists
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Simponi Aria, Remicade, Inflectra, Renflexis, Ixifi, Humira, Enbrel, Cimzia
|
J1602, J1745, Q5103, Q5104, Q5109, J0135, J1438, J0717
|
|
ING-CC-0063
|
Stelara (ustekinumab)
|
Stelara
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J3357, J3358
|
|
ING-CC-0066
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Monoclonal Antibodies to Interleukin-6
|
Actemra
|
J3262
|
|
ING-CC-0071
|
Entyvio (vedolizumab)
|
Entyvio
|
J3380
|
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
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Avastin, Lucentis, Eylea, Macugen, Zirabev, Mvasi
|
J2503, C9257, J9035, J2778, J0178, Q5118, Q5017
|
|
ING-CC-0073
|
Alpha-1 Proteinase Inhibitor Therapy
|
Aralast, Glassia, Prolastin-C, Zemaira
|
J0256, J0257
|
|
ING-CC-0075
|
Rituxan (rituximab) for Non-Oncologic Indications
|
Rituxan, Truxima
|
J9312, Q5115
|
The following clinical criteria documents were endorsed at the August 16, 2019 clinical criteria meeting. To access the clinical criteria information please click here. If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.
Revised clinical criteria effective September 23, 2019
(The following clinical criteria was revised to expand medical necessity indications or criteria.)
ING-CC-0011 Ocrevus (ocrelizumab)
ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
ING-CC-0027 Denosumab Agents
ING-CC-0028 Benlysta (belimumab)
ING-CC-0029 Dupixent (dupilumab)
ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
ING-CC-0038 Human Parathyroid Hormone Agents
ING-CC-0041 Complement Inhibitors
ING-CC-0075 Rituximab Agents for Non-Oncology Indications
ING-CC-0082 Onpattro (patisiran)
ING-CC-0105 Vectibix (panitumumab)
ING-CC-0114 Jevtana (cabazitaxel)
ING-CC-0124 Keytruda (pembrolizumab)
ING-CC-0127 Darzalex (daratumumab)
ING-CC-0128 Tecentriq (atezolizumab)
ING-CC-0134 Provenge (sipuleucel-T)
Revised clinical criteria effective September 23, 2019
(The following clinical criteria were reviewed and may have word changes or clarifications, but had no significant changes to the medical necessity indications or criteria.)
ING-CC-0004 H.P. Acthar Gel (repository corticotropin injection)
ING-CC-0008 Subcutaneous Hormonal Implants
ING-CC-0009 Lemtrada (alemtuzumab)
ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
ING-CC-0020 Tysabri (natalizumab)
ING-CC-0036 Naltrexone Implantable Pellets
ING-CC-0044 Exondys 51 (eteplirsen)
ING-CC-0094 Alimta (pemetrexed disodium)
ING-CC-0099 Abraxane (paclitaxel, protein bound)
ING-CC-0104 Levoleucovorin Agents
ING-CC-0119 Yervoy (ipilimumab)
ING-CC-0125 Opdivo (nivolumab)
ING-CC-0129 Bavencio (avelumab)
ING-CC-0130 Imfinzi (durvalumab)
New clinical criteria effective September 23, 2019
(The following are new clinical criteria.)
ING-CC-0142 Somatuline Depot (lanreotide)
ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)
Revised clinical criteria effective October 1, 2019
(The following current clinical criteria were updated with new procedure and/or diagnosis codes.)
ING-CC-0006 Hyaluronan Injections
ING-CC-0034 Hereditary Angioedema Agents
ING-CC-0041 Complement Inhibitors
ING-CC-0082 Onpattro (patisiran)
ING-CC-0087 Gamifant
ING-CC-0088 Elzonris (tagraxofusp-erzs)
ING-CC-0104 Levoleucovorin Agents
Revised clinical criteria effective December 1, 2019
(The following current clinical criteria were updated with new procedure and/or diagnosis codes.)
ING-CC-0031 Intravitreal Corticosteroid Implants
Revised clinical criteria effective February 1, 2020
(The following clinical criteria listed below might result in services that were previously covered, but now being considered either not medically necessary and/or investigational.)
ING-CC-0001 Erythropoiesis Stimulating Agents
ING-CC-0002 Colony Stimulating Factor Agents
ING-CC-0003 Immunoglobulins
ING-CC-0007 Synagis (palivizumab)
ING-CC-0013 Mepsevii (vestronidase alfa)
ING-CC-0018 Lumizyme (alglucosidase alfa)
ING-CC-0021 Fabrazyme (agalsidase beta)
ING-CC-0022 Vimizim (elosulfase alfa)
ING-CC-0023 Naglazyme (galsulfase)
ING-CC-0024 Elaprase (idursufase)
ING-CC-0025 Aldurazyme (laronidase)
ING-CC-0028 Benlysta (belimumab)
ING-CC-0031 Intravitreal Corticosteroid Implants
ING-CC-0032 Botulinum Toxin
ING-CC-0033 Xolair (omalizumab)
ING-CC-0034 Hereditary Angioedema Agents
ING-CC-0041 Complement Inhibitors
ING-CC-0043 Monoclonal Antibodies to Interleukin-5
ING-CC-0048 Spinraza (nusinersen)
ING-CC-0050 Monoclonal Antibodies to Interleukin-23
ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
ING-CC-0058 Octreotide Agents
ING-CC-0061 GnRH Analogs for the treatment of non-oncologic indications
ING-CC-0062 Tumor Necrosis Factor Antagonists
ING-CC-0063 Stelara (ustekinumab)
ING-CC-0066 Monoclonal Antibodies to Interleukin-6
ING-CC-0071 Entyvio (vedolizumab)
ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy
ING-CC-0075 Rituximab Agents for Non-Oncology Indications
ING-CC-0082 Onpattro (patisiran)
ING-CC-0106 Erbitux (cetuximab)
ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
New clinical criteria effective February 1, 2020
(The following are new clinical criteria.)
ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
ING-CC-0145 Libtayo (cemiplimab-rwlc)
Category: Medicare
The Blue Cross and Blue Shield Association issued a mandate requiring a change in the way we process Host and Home plan HEDIS® STARS Care Gaps, risk adjustment (RADV) and medical records requests. The goal of this mandate is to improve health outcomes and care management for Medicare Advantage out-of-area members.
More information about this mandate will be published in the December 2019 Provider News.
Category: Medicare
The Centers for Medicare & Medicaid Services (CMS) defines an expedited/urgent request as ‘an expedited/urgent request for a determination is a request in which waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in seriously jeopardy.’ Contracted providers should submit requests in accordance with CMS guidelines to allow for organization determinations within the standard turnaround time, unless the member urgently needs care based on the CMS definition of an expedited/urgent request.
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