 Provider News MaineNovember 2020 Anthem Maine Provider NewsBeginning with dates of service on or after February 1, 2021, our policy language has been updated to add Modifier FB to the related coding section and indicate that when used in the adjudication of a claim reimbursement may be affected.
Modifier FB is defined as an item provided without cost to provider, supplier or practitioner, or full credit received for replaced device.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
As a reminder, beginning with dates of service on or after January 1, 2019, we require facilities billing outpatient services on a UB-04 to report current and valid CPT or HCPCS codes and applicable modifiers with all revenue codes, as specified in the National Uniform Billing Committee (NUBC) requirements.
In addition, we require that the facility report any available current and valid CPT or HCPCS code modifiers. Modifiers are applicable when they clarify or improve the accuracy of the procedure being reported.
To review this outpatient facility policy, visit the Reimbursement Policies page at anthem.com.
Beginning with dates of service on or after February 1, 2021, we will update our Bundled Services and Supplies Section 2 Coding list to indicate that the following codes:
- 43281 - laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh,
- 43282 - laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh or other prosthesis,
- 43283 - laparoscopy, surgical, esophageal lengthening procedure,
- 43332 - repair paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis, and
- 43333 - repair paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis,
are not eligible for separate reimbursement when reported with bariatric procedure codes 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887 and 43888.
Additionally, the Bundled Services Section 2 coding list will be updated to include the telehealth originating site facility fee HCPCS code (Q3014) when reported with an E&M code in place of service 11.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
The new professional reimbursement policy for Documentation Standards for Episodes of Care will be effective February 1, 2021. This policy will replace the current Documentation Guidelines for Adaptive Behavior Assessments and Treatment for Autism Spectrum Disorder and Documentation Guidelines for Central Nervous System Assessments and Tests policies. Those policies will be retired as of February 1, 2021. The Documentation Standards for Episodes of Care policy will be considered an administrative policy and will serve as an overarching documentation standards policy.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
In this 60-minute webinar, you will learn how to use Availity's attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers. We will explore key workflow options to fit your organization’s needs, including how to:
- Work a request in the inbox of your Attachments Dashboard
- Enter and submit a web claim including supporting documentation
- Use EDI batch options to trigger a request in your inbox
- Track attachments you submitted using sent and history lists in your Attachments Dashboard
- Get set up to use these tools
As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.
Register for an upcoming webinar session:
- In the Availity Portal, select Help & Training > Get Trained.
- The Availity Learning Center opens in a new browser tab.
- Search for and enroll in a session using one of these options:
- In the Catalog, search by webinar title or keyword.
- To find this specific live session quickly, use keyword medattach.
- Select the Sessions tab to scroll the live session calendar.
- After you enroll, you’ll receive emails with instructions to join the session.
Webinar Dates:
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DATE
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DAY
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TIME
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November 4, 2020
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Wednesday
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Noon to 1:00 p.m.
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November 17, 2020
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Tuesday
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2:00 p.m. to 3:00 p.m.
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December 4, 2020
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Friday
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3:00 p.m. to 4:00 p.m.
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December 15, 2020
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Tuesday
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3:00 p.m. to 4:00 p.m.
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We would like to provide important information regarding submission of the CLIA number on claims for laboratory services that include QW or 90 modifiers. As a reminder, claims filed without the CLIA number are considered incomplete and will reject.
Both paper and electronic claim formats accommodate the CLIA number.
- On the CMS-1500 form, Box 23 (prior authorization) is reserved for the CLIA number.
- On the 837P, REF segments are available: REF (X4) in loops 2300 and 2400, and REF (F4) in loop 2400.
Note: The CLIA number for the referring clinical laboratory should be included in REF (F4).
The following examples illustrate how the CLIA number, as well as procedure code modifiers QW and 90, should be submitted:
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Claim Format
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Location(s) Reserved for Procedure Modifier and CLIA #
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Modifier QW – diagnostic lab service is a CLIA waived test
· CLIA waived tests - simple laboratory examinations and procedures that have an insignificant risk of an erroneous result
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CMS-1500
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Procedure modifier ‘QW’:
Box 24d
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CLIA #: Box 23 prior authorization
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837P
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Procedure modifier ‘QW’: Loop 2400 SV101-3 (1st position)
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CLIA #: Loop 2300 or 2400 REF X4
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Modifier 90 – reference (outside) laboratory
· Referring laboratory – refers a specimen to another laboratory for testing
· Reference laboratory – receives a specimen from another laboratory and performs one or more tests on that specimen
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CMS-1500
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Procedure modifier ‘90’:
Box 24d
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CLIA #:
Box 23 prior authorization
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837P
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Procedure modifier ‘90’:
Loop 2400 SV101-3 – SV101-6
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CLIA #:
Loop 2300 or 2400 REF X4
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CLIA # - referring facility identification:
Loop 2400 REF F4
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Additional information regarding CLIA is available on the CMS website.
If you have questions, please call the telephone number on the back of the member’s identification card.
We are replacing the current Provider Manual with an updated version effective January 1, 2021.
The updated Provider Manual is available on our website at anthem.com.
US Antibiotic Awareness Week is November 18-24, 2020. This one-week observance gives organizations and providers an opportunity to raise awareness on the appropriate use of antibiotics and reduce the threat of antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has over 10 hours of free Continuing Education available for providers.
The CDC promotes Be Antibiotics Aware, an educational effort to raise awareness encouraging safe antibiotic prescribing practices and use. Be Antibiotics Aware has many resources for health care professionals (in outpatient and inpatient settings) including videos such as The Right Tool and Antibiotics Aren’t Always the Answer that can be utilized in provider’s waiting rooms.
Anthem is committed to creating innovative tools that help simplify health care. In pursuit of that commitment, we recently enhanced our digital tool that enables members to share their personal health data with physicians and hospitals. This tool, referred to as My Health Records, merges patient health records from providers who may have cared for an individual member and stores the data in one secure place that is accessible to the member via the Sydney Health mobile app and anthem.com. My Health Records provides a new way for members to access their personal health information from multiple providers’ databases then view, download and share their health data and medical records with doctors via their smartphone or computer.
My Health Records allows members to share important health information with physicians, such as:
- Lab results and historical insights with visualizations
- Medications, conditions, immunizations, vaccinations
- Health records
- Health records of dependents (14 years and under)
- Easy access to provider information
- Personalized health data tracking over time
- Integration for member authorization to more health record data
The enhanced digital tool gives physicians and hospitals a holistic view of a member’s up-to-date health data. This complete health data in one trusted place enables providers and members to feel more confident in making important life decisions easily and quickly.
This tool is now available to Anthem members in our Medicare, Individual, Small Group and Fully Insured Large Group business segments and will be available to members in our Large Group ASO and Anthem National Account business segments in early 2021.
Introducing the Anthem Provider Digital Engagement Supplement to the Provider Manual
Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.
Get payments faster
By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.
Member ID cards go digital
Anthem members are transitioning to digital member identification cards making it easier for them and you. The ID card can be easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.
Anthem makes going digital easy with the Provider Digital Engagement Supplement
From our digital member identification cards to EDI transactions, application programming interfaces and direct data entry, we cover it all in our Provider Digital Engagement Supplement to the provider manual, and on our secure provider portal through Availity. The Supplement outlines our provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits.
The Provider Digital Engagement Supplement to the provider manual is another example of how we are using digital technology to improve the health care experience. We are asking providers to go digital with us no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now and go digital with Anthem.
The following new and revised medical policies were endorsed at the August 13, 2020 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'
Archived clinical guidelines effective December 8, 2020
The following adopted guidelines have been archived and have been replaced by AIM guidelines.
- CG-REHAB-04 - Rehabilitative and Habilitative Services: Medicine/Physical Therapy
- CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
- CG-REHAB-06 - Rehabilitative and Habilitative Services: Speech-Language Pathology
- CG-REHAB-11 - Cognitive Rehabilitation
As we communicated in the October 2017 Network Update, AIM administers pre-service clinical reviews on behalf of Anthem for the services noted below. AIM reviews requests in real time against evidence-based clinical guidelines and Anthem medical policies. Providers are notified via letter or remit message when claims are submitted without the appropriate pre-service review by AIM. If such a letter or message is received, providers will need to obtain a post-service clinical review for the service via the AIM ProviderPortalSM. If the documentation/post-service review request is submitted to Anthem, we notify the provider via another letter or remit message to submit to AIM.
AIM reviews the following services for clinical appropriateness:
- Advanced diagnostic imaging
- Cardiology tests and procedures (e.g. MPI, echocardiography, PCI, cardiac catheterization)
- Medical oncology treatments through the Cancer Care Quality Program
- Radiation oncology treatments (e.g. IMRT, brachytherapy)
- Sleep testing, treatment and supplies
- Genetic testing
- Musculoskeletal (e.g., spine and joint surgeries, pain management)
- Rehabilitative services (physical, speech and occupational therapy)
- Surgical site of care (e.g., gastroenterology, other surgeries will be implemented which will be communicated via Provider News)
Services performed in an emergency or inpatient setting are excluded from AIM programs.
This update applies to local fully-insured Anthem members and members who are covered under a self-insured (ASO) benefit plan, with services medically managed by AIM. It does not apply to BlueCard, Medicare Advantage, Medicaid, Medicare Supplement or Federal Employee Program (FEP) members.
To help prevent delays in claim processing and post-service reviews, ordering providers should submit pre-service requests to AIM in one of the following ways:
- Access AIM ProviderPortal directly at providerportal.com available 24/7 to process orders in real-time
- Access AIM via the Availity web portal at availity.com
For more information, please contact the phone number on the back of the member’s ID card.
The following clinical criteria documents were endorsed at the September 24, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised clinical criteria effective September 30, 2020
(The following criteria were revised to expand medical necessity indications or criteria.)
- ING-CC-0063: Stelara (ustekinumab)
- ING-CC-0086: Spravato (esketamine) Nasal Spray
- ING-CC-0128: Tecentriq (atezolizumab)
New clinical criteria effective September 30, 2020
(The following clinical criteria are new.)
- ING-CC-0179: Blenrep (belantamab mafodotin-blmf)
- ING-CC-0180: Monjuvi (tafasitamab-cxix)
Revised clinical criteria effective October 26, 2020
(The following clinical criteria were revised to expand medical necessity indications or criteria.)
- ING-CC-0081: Crysvita (burosumab-twza)
Reviewed clinical criteria effective October 26, 2020
(The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.)
- ING-CC-0008: Subcutaneous Hormonal Implants
- ING-CC-0012: Brineura (cerliponase alfa)
- ING-CC-0013: Mepsevii (vestronidase alfa)
- ING-CC-0017: Xiaflex (collagenase clostridium histolyticum)
- ING-CC-0018: Lumizyme (alglucosidase alfa)
- ING-CC-0028: Benlysta (belimumab)
- ING-CC-0046: Zinplava (bezlotoxumab)
- ING-CC-0062: Tumor Necrosis Factor Antagonists
Revised clinical criteria effective February 1, 2021
(The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- ING-CC-0011: Ocrevus (ocrelizumab)
- ING-CC-0014: Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
- 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-0086: Spravato (esketamine) Nasal Spray
- ING-CC-0160: Vyepti (eptinezumab-jjmr)
Prior authorization updates
Effective for dates of service on and after February 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
To access the clinical criteria information please click here.
Prior authorization 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 shown in italics in the table below.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0127
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J9999, C9399
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Darzalex Faspro
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* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.
Step therapy updates
Effective for dates of service on and after February 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
To access the clinical criteria information related to step therapy, please click here.
Prior authorization clinical review of the following non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.
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Clinical Criteria
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Status
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Drug(s)
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HCPCS Code
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ING-CC-0160
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Non-preferred
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Vyepti
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J3032
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ING-CC-0160
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Non-preferred
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Vyepti
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C9063
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ING-CC-0011
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Non-preferred
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Ocrevus
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J2350
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Correction to a prior authorization update
In the October 2020 edition of Provider News, we published a prior authorization update regarding clinical criteria ING-CC-0174 on the drug Kesimpta.
- One HCPCS code has been added, J9302. This is the valid code for the drug Kesimpta.
Introducing the Anthem and AMH Health, LLC (AMH Health) Provider Digital Engagement Supplement to the Provider Manual
Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.
Get payments faster
By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.
Member ID cards go digital
Anthem and AMH Health members are transitioning to digital member identification cards making it easier for them and you. The ID card can be easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.
Anthem and AMH Health make going digital easy with the Provider Digital Engagement Supplement
From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available at https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid and Medicare, including medical, dental and vision benefits.
The Provider Digital Engagement Supplement to the provider manual is another example of how we are using digital technology to improve the health care experience. We are asking providers to go digital with Anthem and AMH Health no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Provider Digital Engagement Supplement now by going to https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals. Go digital with Anthem and AMH Health.
Anthem and AMH Health, LLC review the activities of the FDA’s approval of drugs and biologics on a regular basis to understand the potential effects for both our providers and members.
The FDA approves new drugs/biologics using various pathways of approval. Recent studies on the effectiveness of drugs/biologics going through these different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.
Here is a list of the approval pathways the FDA uses for drugs/biologics:
- Standard review – The standard review process follows well-established paths to help ensure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public; watches for problems once drugs and biologics are available to the public; monitors drug/biologic information and advertising; and protects drug/biologic quality. Learn more about the standard review process.
New molecular entities approvals: January - August 2020
Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.
Anthem and AMH Health review the FDA-approved NMEs on a regular basis. To help facilitate the decision-making process, please see the attached PDF list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized.
On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem and AMH Health, LLC (AMH Health). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting June 2020 (Anthem) and the Clinical Criteria Web Posting June 2020 (AMH Health). Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
You now have a new option to have questions answered quickly and easily. With Anthem and AMH Health, LLC Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity. Provider Chat offers:
- Faster access to Provider Services for all questions.
- Real-time answers to your questions about prior authorization and appeals status, claims, benefits, eligibility, and more.
- An easy to use platform that makes it simple to receive help.
- The same high level of safety and security you have come to expect with Anthem and AMH Health.
Chat is one example of how Anthem and AMH Health are using digital technology to improve the health care experience, with the goal of saving valuable time. To get started, access the service through Payer Services on Availity.
On January 1, 2020, Anthem implemented a preferred edit on Medicare Part B eligible continuous glucose monitors (CGMs). The preferred CGM is Freestyle Libre.
Preferred CGM edits do not apply to the following plans/plan types:
- Employer Group Waiver Plans (EGWP) Medicare Advantage Part D (MAPD) through Anthem
- Employer Group Waiver Plans (EGWP) Medicare Advantage (MA only) through Anthem
- Individual Medicare Advantage Plans (MA only) through Anthem
Delivery channels
Only members enrolled in a plan using preferred CGM edits will need to obtain their CGM systems from a retail or mail order pharmacy. Members on a plan without preferred CGM edits will be able to obtain their CGM systems through durable medical equipment providers in addition to retail and mail order pharmacies. Please check member and plan benefits to confirm the available delivery channels for accessing CGM products.
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