 Provider News MaineNovember 2022 Provider Newsletter - Maine Contents State & Federal | Anthem Blue Cross and Blue Shield | Medicare Advantage | November 1, 2022 Personalized Match
Administrative | Anthem Blue Cross and Blue Shield | Commercial | November 1, 2022 Notice of material change/amendment to contract Notices of material changes/amendments to contract - November 2022Notices 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:
- Correction to reimbursement policy: Place of Service - Facility
- Medical policy and clinical guideline updates available on anthem.com
- Specialty pharmacy updates - November 2022
Mail is being forwarded to new post office box addresses for one year.
A recent study indicated that several post office boxes are no longer being utilized by providers. To streamline our internal mail processing, we are retiring these post office boxes and utilizing post office boxes currently being used in the provider locations indicated.
While we have not received any incoming mail from these retiring post office boxes in the last 12 months, should mail be received, it will be forwarded for a 12-month period. This change is effective immediately.
No action is required; this is an informational notification.
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Provider location
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Retiring PO Box number
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Replacement PO Box number
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Maine
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PO Box 201, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 337, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 424, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 430, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 504, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 537, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 540, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 543, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 553, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 555, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 560, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 565, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 697, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 718, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 800, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1010, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1012, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1013, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1018, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1019, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1044, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1050, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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Maine
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Retiring PO Box number
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Replacement PO Box number
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PO Box 1076, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1077, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1079, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1090, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1097, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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PO Box 1098, North Haven CT 06473
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PO Box 533, North Haven CT 06473
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Consider using Availity.com when sharing information with us. Digital submissions are faster and more efficient than mailing. To register with Availity Essentials, use this link.
Providers currently submit prior authorization (PA) requests to AIM Specialty Health®* (AIM) for outpatient diagnostic imaging services. These PA requests are often reviewed based on provider attestation of certain requirements.
As part of our ongoing quality improvement efforts, we want you to know that as of January 1, 2023, some review requests may require documentation to substantiate the attestations that support the clinical appropriateness of the request. This documentation can be uploaded during the intake process.
When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the PA review attestations.
If the request would be denied as not medically necessary, providers can participate in a PA discussion with an AIM physician reviewer.
As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting them to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.
We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.
Accessing claim statuses
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
Working together to streamline processes through technology is a collaborative effort. We appreciate your feedback as we continue improving to meet your expectations. The enhancements we’ve made to the Availity Essentials* Authorization application make it faster, easier, and more efficient to submit digital authorizations for Anthem Blue Cross and Blue Shield members.
View attachments for authorizations submitted — You can now view the attachments you’ve submitted to support your authorization in the Availity Essentials authorization application.
Servicing and rendering provider — We’ve enhanced the Availity Essentials Authorization Application to enable a group option when selecting the servicing and rendering provider.
View correspondence — Access status and decision letters right from the Authorization Application Dashboard. Letters can also be downloaded or printed if needed.
Enhanced provider status — Out-of-network and in-network provider statuses are now enhanced to return fewer errors associated with provider status.
Expanded search — Search rendering and serving provider by NPI and ZIP code for quicker results.
Procedure code enhancement — Add the procedure code on an outpatient authorization for more accurate submission.
Case update features — You can now update your authorization right from your Authorization Application Dashboard.
Training sessions on the Availity Essentials authorization application are still available
Whether you prefer live training webcasts, on-demand webinar recordings, or a resource guide, we have everything you need to learn more about the Availity Essentials Authorization Application and how to make the most of it. Use this link to access the training option best for you.
The next live webcast is Wednesday, November 9, 2022, at 11 a.m. ET. Register here.
When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for Anthem Blue Cross and Blue Shield claims
The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.
Submitting Anthem Blue Cross and Blue Shield claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the
CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
New learnings added to the Provider Learning Hub.
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
The following new and revised medical policies and clinical guidelines were endorsed at the August 11, 2022, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.
Medical policy updates
Revised medical policies effective August 18, 2022
The following policies were revised to expand medical necessity indications or criteria:
- MED.00129 Gene Therapy for Spinal Muscular Atrophy
- SURG.00121 Transcatheter Heart Valve Procedures
New medical policy effective August 22, 2022
The following policy is new:
- MED.00140 Gene Therapy for Beta Thalassemia
Revised medical policy effective September 7, 2022
The following policy was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- MED.00129 Gene Therapy for Spinal Muscular Atrophy
New medical policy effective September 28, 2022
The following policy is new:
- MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy
Revised medical policies effective September 28, 2022
The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
- SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
Revised medical policies effective September 28, 2022
The following policies were updated with new CPT®/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
- GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
- GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- LAB.00015 Detection of Circulating Tumor Cells
- LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease
- MED.00098 Hyperoxemic Reperfusion Therapy
- RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00120 Internal Rib Fixation Systems
- TRANS.00038 Thymus Tissue Transplantation
Archived medical policy effective October 5, 2022
The following policy has been archived:
- GENE.00034 SensiGene® Fetal RhD Genotyping Test
Revised medical policies effective October 5, 2022
The following policies were revised to expand medical necessity indications or criteria:
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- SURG.00119 Endobronchial Valve Devices
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
Revised medical policies effective October 5, 2022
The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
- DME.00025 Self-Operated Spinal Unloading Devices
- DME.00041 Ultrasonic Diathermy Devices
- DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
- GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site
- GENE.00020 Gene Expression Profile Tests for Multiple Myeloma
- GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies
- GENE.00058 TruGraf Blood Gene Expression Test for Transplant Monitoring
- LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00011 Selected Protein Biomarker Algorithmic Assays
- LAB.00028 Serum Biomarker Tests 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
- LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia
- LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
- MED.00055 Wearable Cardioverter Defibrillators
- MED.00082 Quantitative Sensory Testing
- MED.00089 Quantitative Muscle Testing Devices
- MED.00096 Low-Frequency Ultrasound Therapy for Wound Management
- MED.00103 Automated Evacuation of Meibomian Gland
- MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring System.
- OR-PR.00007 Microprocessor Controlled Knee-Ankle-Foot Orthosis
- RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
- RAD.00061 PET/MRI
- RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
- SURG.00008 Mechanized Spinal Distraction Therapy
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00077 Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
- 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.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
- SURG.00107 Prostate Saturation Biopsy
- SURG.00114 Facet Joint Allograft Implants for Facet Disease
- SURG.00128 Implantable Left Atrial Hemodynamic Monitor
- 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.00153 Cardiac Contractility Modulation Therapy
- SURG.00156 Implanted Artificial Iris Devices
- SURG.00157 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
Archived medical policy effective November 6, 2022
The following policy has been archived and has been replaced by AIM guidelines:
- SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
New medical policies effective February 1, 2023
The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- DME.00049 External Upper Limb Stimulation for the Treatment of Tremors*
- DME.00050 Remote Devices for Intermittent Monitoring of Intraocular Pressure*
- LAB.00049 Artificial Intelligence-Based Software for Prostate Cancer Detection*
- MED.00141 High-volume Colonic Irrigation*
- TRANS.00040 Hand Transplantation*
Revised medical policies effective February 1, 2023
The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:
- DME.00044 Robotic Arm Assistive Devices*
- SURG.00079 Nasal Valve Repair*
Clinical guideline updates
Revised clinical guideline effective August 24, 2022
The following adopted guideline was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- CG-MED-68 Therapeutic Apheresis
Revised clinical guidelines effective September 28, 2022
The following adopted guidelines were updated with new CPT®/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:
- CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
- CG-MED-68 Therapeutic Apheresis
- CG-SURG-97 Cardioverter Defibrillators
Unadopted clinical guideline effective October 1, 2022
The criteria in the following guideline will no longer be applied.
- CG-SURG-96 Intraocular Telescope
Revised clinical guideline effective October 5, 2022
The following adopted guideline was revised to expand medical necessity indications or criteria:
- CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
Revised clinical guidelines effective October 5, 2022
The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:
- CG-BEH-02 Adaptive Behavioral Treatment
- CG-DME-10 Durable Medical Equipment
- CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
- CG-DME-44 Electric Tumor Treatment Field (TTF)
- CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
- CG-MED-65 Manipulation Under Anesthesia
- CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
- CG-MED-69 Inhaled Nitric Oxide
- CG-MED-83 Site of Care: Specialty Pharmaceuticals
- CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
- CG-REHAB-08 Private Duty Nursing in the Home Setting
- CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
- CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
- CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
- CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Revised clinical guidelines effective February 1, 2023
The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary:
- CG-DME-31 Powered Wheeled Mobility Devices*
- CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status*
- CG-GENE-13 Genetic Testing for Inherited Diseases*
Effective November 6, 2022, Anthem Blue Cross and Blue Shield will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
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 Availity* at availity.com.
- For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Additionally, you may access and download a copy of the current and upcoming guidelines here.
In the August edition of Provider News, we announced a Place of Service — Facility reimbursement policy indicating that evaluation & management (E/M) services and other professional services must be billed on a CMS-1500 claim form and are not reimbursable when billed on a UB-04 claim form (excluding E/M services rendered in an emergency room and billed with ER revenue codes).
It has come to our attention that some of the preventive counseling CPT® codes mentioned in the August article were listed incorrectly. The correct preventive counseling CPT codes are 99401–99404, 99411, and 99412, and are not reimbursable when billed in an outpatient setting of a facility effective with dates of service on or after February 1, 2023.
Please note, however, that the revenue codes 960-983 (excluding revenue code 964) and the E/M services noted in the August edition were listed correctly in the Place of Service — Facility reimbursement policy effective with dates of service on or after November 1, 2022.
For specific policy details, visit the reimbursement policy page on our provider website.
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health®* (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
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.
Prior authorization updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
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Clinical Criteria
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Drug
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HCPCS or CPT® code(s)
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ING-CC-0002*+
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Fylnetra (pegfilgrastim-pbbk)
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J3590
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ING-CC-0002*
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Rolvedon (eflapegrastim-xnst)
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C9399, J3490, J3590
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ING-CC-0002*
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Stimufend (pegfilgrastim-fpgk)
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C9399, J3490, J3590
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ING-CC-0072+
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Cimerli (ranibizumab-cqrn)
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J3590
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ING-CC-0220+
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Xenpozyme (olipudase alfa)
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C9399, J3490, J3590
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ING-CC-0221+
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Spevigo (spesolimab-sbzo)
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C9399, J3490, J3590
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Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Site of care updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
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Clinical Criteria
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Drug
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HCPCS or CPT code(s)
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ING-CC-0065+
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Advate (factor viii (antihemophilic factor, recombinant))
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J7192
|
|
ING-CC-0065
|
Adynovate (factor vii)
|
J7207
|
|
ING-CC-0065
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Afstyla (antihemophilic factor (recombinant) single chain))
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J7210
|
|
ING-CC-0065
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Alphanate (antihemophilic factor viii)
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J7186
|
|
ING-CC-0065
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Eloctate (recombinant antihemophilic factor)
|
J7205
|
|
ING-CC-0065
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Esperoct (factor viii recombinant, glycopegylated)
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J7204
|
|
ING-CC-0065
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factor viii, anti-hemophilic factor (porcine)
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J7191
|
|
ING-CC-0065
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Hemlibra (emicizumab-kxwh)
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J7170
|
|
ING-CC-0065
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Hemofil M ((factor viii) human plasma-derived)
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J7190
|
|
ING-CC-0065
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Humate-P (antihemophilic factor viii)
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J7187
|
|
ING-CC-0065
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Jivi (factor viii, recombinant, pegylated-aucl)
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J7208
|
|
ING-CC-0065
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Koate DVI ((factor viii) human plasma-derived)
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J7190
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|
ING-CC-0065
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Kogenate-FS (factor viii (antihemophilic factor, recombinant))
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J7192
|
|
ING-CC-0065
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Kovaltry (factor viii (antihemophilic factor, recombinant))
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J7211
|
|
ING-CC-0065
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Novoeight (factor viii (antihemophilic factor, recombinant))
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J7182
|
|
ING-CC-0065
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Nuwiq (factor viii (antihemophilic factor, recombinant))
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J7209
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|
ING-CC-0065
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Obizur (antihemophilic factor viii (recombinant))
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J7188
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ING-CC-0065
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Recombinate (factor viii (antihemophilic factor, recombinant))
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J7192
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ING-CC-0065
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Vonvendi (von willebrand factor)
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J7179
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ING-CC-0065
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Wilate (antihemophilic factor viii)
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J7183
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ING-CC-0065
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Xyntha (factor viii (antihemophilic factor, recombinant))
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J7185
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ING-CC-0065
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Xyntha Solofus (factor viii (antihemophilic factor, recombinant))
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J7185
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ING-CC-0148+
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AlphaNine SD (coagulation factor ix (human))
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J7193
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ING-CC-0148
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Alprolix (recombinant coagulation factor ix)
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J7201
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ING-CC-0148
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Benefix (factor ix recombinant)
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J7195
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ING-CC-0148
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Idelvion (factor ix)
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J7202
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ING-CC-0148
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Ixinity (factor ix)
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J7195
|
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ING-CC-0148
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Mononine (coagulation factor ix (human))
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J7193
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ING-CC-0148
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Profilnine SD (factor ix complex human)
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J7194
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ING-CC-0148
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Rebinyn (glycopegylated)
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J7203
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ING-CC-0148
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Rixubis (factor ix recombinant)
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J7200
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ING-CC-0149+
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Coagadex (factor x)
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J7175
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ING-CC-0149
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Corifact (factor xiii concentrate (human))
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J7180
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ING-CC-0149
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Feiba (anti-inhibitor coagulant complex)
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J7198
|
|
ING-CC-0149
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Fibryga (human fibrinogen)
|
J7177
|
|
ING-CC-0149
|
NovoSeven RT (factor viia recombinant)
|
J7189
|
|
ING-CC-0149
|
RiaSTAP (fibrinogen concentrate)
|
J7178
|
|
ING-CC-0149
|
Sevenfact (factor vlla recombinant)
|
J7212
|
|
ING-CC-0149
|
Tretten (coagulation factor xiii a-subunit (recombinant))
|
J7181
|
Step therapy updates
Effective for dates of service on and after February 1, 2023, 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.
Clinical Criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro, and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long‑acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.
Access our Clinical Criteria to view the complete information for these step therapy updates.
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Clinical Criteria
|
Status
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Drug
|
HCPCS or CPT code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Fylnetra
|
J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Rolvedon
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Stimufend
|
C9399, J3490, J3590
|
|
ING-CC-0002
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Preferred
|
Neulasta
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Neulasta OnPro
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
ING-CC-0002
|
Non-preferred
|
Nyvepria
|
Q5122
|
|
ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
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This is a courtesy notice that there is a non-material change in the Clinical Criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).
Quantity limit updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT code(s)
|
|
ING-CC-0017+
|
Xiaflex (collagenase clostridium histolyticum)
|
J0775
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0182+
|
Feraheme (ferumoxytol)
|
Q0138
|
|
ING-CC-0182
|
Ferrlecit (ferric gluconate)
|
J2916
|
|
ING-CC-0182
|
Infed (iron dextran)
|
J1750
|
|
ING-CC-0182
|
Injectafer (ferric injection)
|
J1439
|
|
ING-CC-0182
|
Monoferric (ferric derisomaltose)
|
J1437
|
|
ING-CC-0182
|
Venofer (iron sucrose)
|
J1756
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered AMH Health, LLC.
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.
FAQ
How does AMH Health retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on AMH Health secure network drives.
Why does AMH Health need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
|
HCPCS or CPT® codes
|
Medicare Part B drugs
|
|
C9399, J3490, J3590, J9999
|
Opdualag (nivolumab and relatlimab-rmbw)
|
|
C9096
|
Releuko (filgrastim-ayow)
|
|
A9699
|
Pluvicto (lutetium lu 177 vipivotide tetraxetan)
|
Find Care, the doctor finder and transparency tool in the AMH Health, LLC online directory, provides AMH Health members with the ability to search for in-network providers using the secure member website at anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetic order, and provider name.
Beginning January 1, 2023, or later, an additional sorting option will be available for members to search by provider performance called Personalized Match. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Provider pairings with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetic order, and provider name.
- You may review a copy of the Personalized Match methodology which has been posted on Availity* – our secure web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > AMH Health > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at availity.com.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to availity.com.
Going forward, AMH Health will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.
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