 Provider News MaineOctober 2020 Anthem Maine Provider NewsWe continue to be dedicated to delivering access to quality care for our members, providing higher value to our customers and helping improve the health of our communities. In an ongoing effort to promote accurate claims processing and payment, we are taking additional steps to assess selected claims for evaluation and management (E/M) services submitted by professional providers. Beginning on January 1, 2021, we will be using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.
Providers should report E/M services in accordance with the American Medical Association (AMA) CPT® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The appropriate level of service is based primarily on the documented medical history, examination and medical decision-making. Counseling, coordination of care, the nature of the presenting problem and face-to-face time are considered contributing factors. The coded service should reflect and not exceed that needed to manage the member’s condition(s).
Claims will be selected from providers who are identified as coding at a higher E/M level as compared to their peers with similar risk-adjusted members. Prior to payment, we will review the selected E/M claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is higher than the E/M code level supported on the claim. If the E/M code level submitted is higher than the E/M code level supported on the claim, we reserve the right to:
- Deny the claim and request resubmission of the claim with the appropriate E/M level,
- Pend the claim and request documentation supporting the E/M level billed, and/or
- Adjust reimbursement to reflect the lower E/M level supported by the claim.
The maximum level of service for E/M codes will be based on the complexity of the medical decision-making and reimbursed at the supported E/M code level and fee schedule rate.
This initiative will not impact every level four (4) or five (5) E/M claim. Providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.
Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute).
If you have questions on this program, contact the Provider Call Center.
We value the quality and commitment with which you serve your patients and our members. We are notifying you about a national drug code (NDC) requirement for drugs administered in a physician’s office or outpatient facility setting for local plan and BlueCard member claims only. This notice does not apply to claims for members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP) or coordination of benefits/secondary claims.
For dates of service on and after December 16, 2020, all providers are required to supply the 11-digit NDC – along with the information below – when billing for injections and other drug items on the CMS-1500 and UB-04 claim forms as well as on 837 electronic transactions.
- The applicable Healthcare Common Procedure Coding System (HCPCS) code or Current Procedural Terminology (CPT) code
- Number of HCPCS code or CPT code units
- The 11-digit NDC(s), including the N4 qualifier
- Dosage unit of measurement (F2, GR, ML, UN, ME)
- Number of NDC units dispensed (must be greater than 0)
To help ensure accurate and timely claims payments, it is important that you provide the NDC information as outlined above when filing claims to us. We will reject any line items on claims with dates of service on and after December 16, 2020, when the above information is not included regarding drugs.
If you have further questions, please contact the telephone number on the back of the member’s ID card.
If you have questions, you now have a new option to have them answered quickly and easily. With Anthem Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.
Anthem Chat benefits include:
- Faster access to provider services for all questions
- Real-time answers to your questions about prior authorization, appeals status, claims, benefits, eligibility, and more
- Easy to use platform making it simpler to receive help
- Same high level of safety and security you have come to expect with Anthem
Chat is one example of how we are using digital technology to improve the health care experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.
To access Provider Chat:
- Select Payer Spaces
- Select Anthem
- From Applications, select Chat
Anthem’s collaborative partnerships with oncology practices, which include sharing of relevant data, have helped drive improved outcomes. Our ‘Potentially Avoidable Admissions During Chemo’ model uses predictive analytics to equip oncologists with actionable, patient-level data to highlight those at greatest risk for complications during chemotherapy.
Since the launch of this model, early results indicate success, as observed by a 13% reduction in avoidable inpatient admissions.1
Our oncology partners have recognized the value of this predictive modeling capability and routinely supplement their own information to proactively outreach to patients who may benefit from additional support during treatment.
Mary Scott, RN, from City of Hope, a leading national cancer center, said the following about how this data enables them make better decisions about patient care. “…best part [of this model] is having some data and some information and some specifics about patients that are deemed to be at risk and keeping them out of the hospital, which is a pretty critical part of our work. I think with the Anthem information we've been able to tackle that in a much better and more organized fashion because they provide us with a list of patients that are high risk, medium risk, and low risk for admission, and people who are on chemotherapy. These regimens can be pretty complicated, pretty toxic, and it helps us to make those better decisions for their care.”
Watch this video to hear more about how our collaborative partnerships with oncology practices is leading to improved outcomes.
For more information on Anthem’s Cancer Care Solutions, email cancer.quality@anthem.com.
Beginning October 1, 2020, most Anthem ACA-complaint non-grandfathered health plans will cover generic aromatase inhibitors at 100%, no member cost share for members who are prescribed these drugs for prevention of breast cancer and use an in-network pharmacy. Prior authorization will be required; providers will need to complete a questionnaire and submit to IngenioRx for consideration. Women must be 35 years or older and have no history of breast cancer.
This coverage change aligns with the updated USPSTF “B” recommendation regarding Breast Cancer: Medication Use to Reduce Risk. This updated recommendation now includes aromatase inhibitors among medications that can reduce risk of breast cancer (in addition to tamoxifen or raloxifene). The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects.
Providers can contact the provider service number on the back of the member ID card to determine if a member’s plan includes this benefit.
As providers, you are committed to providing the best care for your patients – our members. That care may now include telehealth visits. Recognizing the continuing increased need for telephone and virtual services during the COVID-19 public health emergency, the U.S. Department of Health and Human Services (HHS) has given additional consideration to the treatment of telephone-only services in the HHS-operated Risk Adjustment Program. HHS has clarified that telephone-only service CPT codes (98966-98968 and 99441-99443) are valid for the Risk Adjustment Program. Telephone-only visits may benefit your patients who have not participated in, or felt comfortable using, a telehealth video visit. Thank you for your continued commitment to assessing your patients’ health and closing possible gaps in care.
If you have any questions please contact Alicia Estrada, the Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.
Providers may now learn how to use Availity's attachment tools to submit and track supporting documentation electronically by attending one of the upcoming live webinars hosted by Availity.
The attachments application is a multi-payer, multi-workflow feature. It allows inclusion of multiple records across a variety of workflows and request types to support different business processes for payers.
By attending one of the upcoming webinars, attendees will learn both the digital and electronic processes that include:
- How your organization gets set up
- Demonstrations of the tools used to submit attachments via Availity Portal
- Navigating the Attachments dashboard
- View electronic records of your submissions
As part of the session, we will answer questions and provide handouts and a job aid for future reference.
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 (medattach).
- Select the Sessions tab to scroll the live session calendar.
- After you enroll, you will receive emails with instructions to join the session.
October/November Dates
- Wednesday, October 7, 2020, 4:00 p.m. – 5:00 p.m.
- Tuesday, October 20, 2020, 11:00 a.m. – 12:00 p.m.
- Wednesday, November 4, 2020, 4:00 p.m. – 5:00 p.m.
- Tuesday, November 17, 2020, 2:00 p.m. – 3:00 p.m.
Where can you find more help?
Select Help & Training > Find Help to display Availity Help in a new browser window.
Use Contents to display topics.
Depending on your needs, consider exploring these topics:
- Claim submission
- Attachments (new)
- Medical attachments (legacy)
We offer you the ability to have a copy of an Anthem member’s ID card without having to physically handle the ID card. This easy, low-touch access to view a member’s ID card is available from the Availity portal.
When conducting an eligibility and benefits inquiry for Anthem members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: the Availity portal requires you to enter the member’s ID number as well as a date of birth or the member’s first and last name into the search options in order to submit an E&B inquiry.
Images of both the front and back of the member ID card are available, allowing you to get all of the pertinent information without the need to make a phone call. The images can be saved directly to your practice management system as PDF files.
Another option available is to access the member’s digital version of their ID card as many members have transitioned to using a digital card instead of a paper card. Members are able to fax or email a copy of the electronic ID card from their phone/app.
We encourage you to integrate these options into your workflow now.
The What Matters Most online training course for providers and office staff addresses gaps in care and offers approaches to communication with patients. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.
The What Matters Most training can be accessed at: www.patientexptraining.com
The following new and revised medical policies and clinical guidelines were endorsed at the August 13, 2020 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.'
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 policy effective September 1, 2020
The following policy was revised to expand medical necessity indications or criteria.
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
Reviewed medical policy effective September 1, 2020
The following policy was reviewed and may have coding updates, but had no significant changes to the policy position or criteria.
- GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies
Coding update effective September 1, 2020
The following policy was updated with new procedure and/or diagnosis codes.
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
Coding updates effective October 1, 2020
The following policies were updated with new procedure and/or diagnosis codes.
- GENE.00037 - Genetic Testing for Macular Degeneration
- OR-PR.00005 - Upper Extremity Myoelectric Orthoses
- OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
- SURG.00127 - Sacroiliac Joint Fusion
- SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- TRANS.00031 - Hematopoietic Stem Cell Transplant for Autoimmune Disease & Misc. Solid Tumors
- TRANS.00035 - Other Stem Cell Therapy
Reviewed medical policies effective October 7, 2020
The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.
- ADMIN.00001 - Medical Policy Formation
- ADMIN.000006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
- DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
- DME.00025 - Self-Operated Spinal Unloading Devices
- GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
- GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
- GENE.00034 - SensiGene® Fetal RhD Genotyping Test
- GENE.00046 - Prothrombin (Factor II) Mutation Testing
- GENE.00047 - Methylenetetra-hydrofolate Reductase Mutation Testing
- LAB.00011 - Analysis of Proteomic Patterns
- LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation 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
- LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
- 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
- OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
- 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.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.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.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
- TRANS.00004 - Cell Transplantation (Adrenal-Brain, Fetal Mesencephalic, and Fetal Xenograft)
Archived medical policy effective October 7, 2020
The following policy has been archived.
- RAD.00062 - Intravascular Optical Coherence Tomography (OCT)
New medical policies effective January 1, 2021
The following policies are new and may result in services previously covered now being considered either not medically necessary and/or investigational.
- MED.00134 - Non-invasive Heart Failure and Arrhythmia Management and Monitoring System
- SURG.00156 - Implanted Artificial Iris Devices
- SURG.00157 - Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
Revised medical policies effective January 1, 2021
The following policies listed below were revised and might result in services previously covered, but now being considered either not medically necessary and/or investigational.
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
- MED.00103 - Automated Evacuation of Meibomian Gland
- SURG.00077 - Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
- SURG.00112 - Implanted Peripheral (Occipital, Supraorbital and Trigeminal) Nerve Stimulation
- SURG.00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
Revised clinical guidelines effective August 20, 2020
The following guidelines were revised to expand medical necessity indications or criteria.
- CG-GENE-03 - BRAF Mutation Analysis
- CG-SURG-27 - Gender Reassignment Surgery
- CG-SURG-59 - Vena Cava Filters
- CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Revised clinical guidelines effective August 20, 2020
The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the guideline position or criteria.
- CG-MED-55 - Site of Care: Advanced Radiologic Imaging
- CG-MED-83 - Site of Care: Specialty Pharmaceuticals
- CG-SURG-52 - Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services
Coding updates effective October 1, 2020
The following guidelines were updated with new procedure and/or diagnosis codes.
- CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
- CG-MED-68 - Therapeutic Apheresis
- CG-MED-76 - Magnetic Source Imaging and Magneto-encephalography
- CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
- CG-SURG-09 - Temporomandibular Disorders
- CG-SURG-72 - Endothelial Keratoplasty
- CG-SURG-92 - Paraesophageal Hernia Repair
- CG-SURG-95 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention
Revised clinical guideline effective October 1, 2020
The following guideline was reviewed and may have word changes or clarifications, but had no significant changes to the guideline position or criteria.
- CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use
Revised clinical guidelines effective October 7, 2020
The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the guideline position or criteria.
- CG-DME-10 - Durable Medical Equipment
- CG-DME-44 - Electric Tumor Treatment Field (TTF)
- CG-MED-63 - Treatment of Hyperhidrosis
- CG-MED-65 - Manipulation Under Anesthesia
- CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
- CG-MED-69 - Inhaled Nitric Oxide
- CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
- CG-REHAB-08 - Private Duty Nursing
- CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
- 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
Archived clinical guideline effective November 1, 2020
This guideline has been archived and is now an AIM Clinical Guideline.
- CG-SURG-74 - Total Ankle Replacement
Revised clinical guideline effective January 1, 2021
The following guideline was revised and may have resulted in services that were previously covered now being considered either not medically necessary and/or investigational.
- CG-SURG-28 - Transcatheter Uterine Artery Embolization
Effective January 1, 2021, Anthem will classify with an evaluation and management (E/M) code level the intensity/complexity of emergency department (ED) interventions a facility utilizes to furnish all services indicated on the claim. E/M services will be reimbursed based on this classification. Facilities must utilize appropriate HIPAA-compliant codes for all services rendered during the ED encounter. If the E/M code level submitted is higher than the E/M code level supported on the claim, we reserve the right to perform one of the following:
- Deny the claim and request resubmission at the appropriate level or request the provider submit documentation supporting the level billed
- Adjust reimbursement to reflect the lower ED E/M classification
- Recover and/or recoup monies previously paid on the claim in excess of the E/M code level supported
Please refer to the Emergency Department: Level of Evaluation and Management Services reimbursement policy for additional details on the Reimbursement Policies page at anthem.com.
Facilities that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process in accordance with the terms of their contract. Claims disputes require a statement providing the reason the intensity/complexity would require a different level of reimbursement and the medical records which should clearly document the facility interventions performed and referenced in that statement.
Beginning with dates of service on or after January 1, 2021, we will update the policy language to indicate modifier 90 will not allow reimbursement when reported in a place of service office (11). Modifier 90 is defined as Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.
For more information about this policy, visit the Reimbursement Policies page at anthem.com.
In the May and August 2020 editions of the Provider News, we announced the following change to our Claims Requiring Additional Documentation policy (Facility) that was scheduled to take effect on October 1, 2020.
- Outpatient facility claims reimbursed at a percent of charge with billed charges above $20,000 will require an itemized bill to be submitted with the claim.
Please be advised we are delaying the implementation of the above policy change until further notice.
As we communicated in the August 2020 edition of Provider News, AIM Specialty Health® (AIM), a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints for Anthem members effective November 1, 2020. Replacement and revision surgeries for procedures such as total joint of ankle, correction of hallux valgus, and hammertoe repair are included.
The AIM Musculoskeletal program follows Anthem Clinical Guidelines that state the services must be delivered by a qualified provider within the scope of their licensure. Qualified providers acting within the scope of their license, including podiatrists, who intend to perform certain elective surgeries of the small joints procedures should request prior-authorization for those services through AIM.
AIM will begin accepting prior authorization requests on October 26, 2020 for dates of service on and after November 1, 2020. Prior authorization requests may be submitted via the AIM ProviderPortal or by calling 866-714-1107, Monday through Friday.
We invite you to take advantage of upcoming training sessions that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. You can register for the one hour training sessions using the links below:
We value your participation in our network and look forward to working with you to help improve the health of our members.
In the June 2020 edition of Provider News, we announced that AIM Specialty Health® (AIM), a separate company, would transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Rehabilitative Service Clinical Appropriateness Guidelines as part of the AIM Rehabilitation Program beginning October 1, 2020. Please be advised that the effective date of this transition has been delayed. The new transition date is December 1, 2020.
Effective with dates of service on or after January 1, 2021, additional pharmacy codes will be included in the Federal Employee Program® (FEP®) plans (member IDs beginning with an “R”) prior authorization review process for specific specialty drugs. (See table below for a list of the additional drugs.) The prior authorization review includes review of site-of-care criteria for outpatient hospital-based settings. As a result of this change, on and after January 1, 2021, services provided for any of the additional drugs without a prior authorization will be denied.
FEP will continue to review FEP medical policy criteria for medical necessity, and Anthem’s clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be utilized to review site-of-care criteria.
What’s new beginning with dates of service on or after January 1, 2021 for the “new” drugs listed below?
- Prior to administering the drugs in any setting, a prior authorization must be completed in order to evaluate if the drug meets clinical criteria. FEP will begin accepting prior authorization requests for these specialty drugs on December 14, 2020 for dates of service on and after January 1, 2021. Request prior authorization review by calling FEP at 800-860-2156.
- Outpatient hospital-based settings will require a site-of-care review for medical necessity as part of the prior authorization review. Hospital-based facilities contracted with Anthem for lower drug and administration costs, non-hospital infusion clinics, provider offices, and home infusion providers will not require a site-of-care review.
- A provider toolkit aligned to Anthem’s clinical guideline (CG-Med83) will be provided to providers requiring a site-of-care review, either by fax or e-review. For outpatient hospital settings that do not meet clinical criteria, a dedicated clinical team will work with you to identify alternate lower level of care sites that can safely administer the drug.
- In the event that there are no infusion centers within 30 miles of the member’s place of residence, or there are no home infusion providers able to service the member’s residence, the hospital-based setting will be approved.
- If the prior authorization is denied for either the drug not meeting medical necessity or the site-of-care not meeting medical necessity, providers should follow the disputed claim/service process. To obtain the current process, please contact FEP at 800-860-2156.
- Services provided on or after January 1, 2021, without prior authorization will result in a denial of claims payment.
Additional drugs requiring medical necessity and site-of-care review as of January 1, 2021.
|
Drug
|
Code
|
FEP Medical Policy
|
|
Actemra®
|
J3262
|
5.70.12
|
|
Aralast®
|
J0256
|
5.45.09
|
|
Fabrazyme®
|
J0180
|
5.30.35
|
|
Fasenra®
|
J0517
|
5.45.07
|
|
Glassia®
|
J0257
|
5.45.09
|
|
Ilaris®
|
J0638
|
5.70.09
|
|
Nucala®
|
J2182
|
5.45.07
|
|
Ocrevus®
|
J2350
|
5.60.28
|
|
Prolastin®
|
J0256
|
5.45.09
|
|
Ultomiris®
|
J1303
|
5.85.33
|
|
Xolair®
|
J2357
|
5.45.02
|
|
Zemaira®
|
J0256
|
5.45.09
|
These changes apply to Anthem FEP members (member IDs beginning with an “R”) who are receiving the specialty drugs listed above through their medical benefits. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits. For more information, such as clinical criteria for specialty drugs and level of care, please contact FEP at 800-860-2156.
We review the activities of the Food and Drug Administration (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. Click this link to learn more about the standard review process.
- Fast track – Fast track is a process designed to facilitate the development, and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Click this link to learn more about the fast track process.
- Priority review – A priority review designation means FDA’s goal is to take action on an application within 6 months. Click this link to learn more about the priority review process.
- Breakthrough therapy – A process designed to expedite the development and review of drugs/biologics that may demonstrate substantial improvement over available therapy. Click this link to learn more about the breakthrough therapy process.
- Orphan review – Orphan review is the evaluation and development of drugs/biologics that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Click this link to learn more about the orphan review process.
- Accelerated approval – These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. Click this link to learn more about the accelerated approval 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.
We review the FDA-approved NMEs on a regular basis. To help facilitate the decision-making process, we have attached to this article a list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized. 
Prior authorization updates
Effective for dates of service on and after January 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 the national drug code (NDC) 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.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0170
|
J3590, C9399
|
Uplizna
|
|
ING-CC-0172
|
J3490, J3590, C9399
|
Viltepso
|
|
ING-CC-0173
|
J3490, J3590
|
Enspryng
|
|
ING-CC-0174
|
J3490, J3590, C9399
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Kesimpta
|
|
ING-CC-0168
|
J3590, J9999, J3490
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Tecartus
|
|
*ING-CC-0171
|
J3490, J3590, J9999
|
Zepzelca
|
|
*ING-CC-0169
|
J3490, J3590, J9999, C9399
|
Phesgo
|
|
*ING-CC-0175
|
J9015
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Proleukin
|
|
*ING-CC-0176
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J9032
|
Beleodaq
|
|
*ING-CC-0178
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J9262
|
Synribo
|
|
*ING-CC-0177
|
J3304
|
Zilretta
|
|
ING-CC-0015
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J3490
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Milprosa Vaginal System
|
|
*ING-CC-0100
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C9065
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Istodax
|
|
ING-CC-0038
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J3110
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Forteo
|
|
*ING-CC-0002
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J3590
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Nyvepria
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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 January 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 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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Status
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Drug
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HCPCS Code
|
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*ING-CC-0002
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Preferred
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Neulasta
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J2505
|
|
*ING-CC-0002
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Preferred
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Udenyca
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Q5111
|
|
*ING-CC-0002
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Non-preferred
|
Fulphila
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Q5108
|
|
*ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
|
*ING-CC-0002
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Non-preferred
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Nyvepria
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J3590
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.
The following clinical criteria document was endorsed at the August 12, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised clinical criteria effective January 1, 2021
(The following criteria was reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- ING-CC-0048 - Spinraza (nusinersen)
The following clinical criteria documents were endorsed at the August 21, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised clinical criteria effective September 1, 2020
(The following criteria were revised to expand medical necessity indications or criteria.)
- ING-CC-0124 - Keytruda (pembrolizumab)
- ING-CC-0125 - Opdivo (nivolumab)
- ING-CC-0129 - Bavencio (avelumab)
New clinical criteria effective September 1, 2020
(The criteria below are new.)
- ING-CC-0169 - Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)
- ING-CC-0172 - Viltepso (viltolarsen)
- ING-CC-0173 - Enspryng (satralizumab-mwge)
- ING-CC-00174 – Kesimpta (ofatumamab)
New clinical criteria effective September 21, 2020
(The criteria below are new.)
- ING-CC-0166 - Trastuzumab Agents Step Therapy
- ING-CC-0167 - Rituximab Agents for Oncologic Indications Step Therapy
Revised clinical criteria effective September 21, 2020
(The following criteria were revised to expand medical necessity indications or criteria.)
- ING-CC-0001 - Erythropoiesis Stimulating Agents
- ING-CC-0009 - Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
- ING-CC-0029 - Dupixent (dupilumab)
- ING-CC-0038 - Human Parathyroid Hormone Agents
- ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
- ING-CC-0050 - Monoclonal Antibodies to Interleukin-23
- ING-CC-0064 - Interleukin-1 Inhibitors
- ING-CC-0104 - Levoleucovorin Agents
- ING-CC-0132 - Mylotarg (gemtuzumab ozogamicin)
- ING-CC-0139 - Evenity (romosozumab-aqqg)
- ING-CC-0152 - Vyondys 53 (golodirsen)
Revised clinical criteria effective September 21, 2020
(The following criteria was reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- ING-CC-0004 - P. Acthar Gel (repository corticotropin injection)
- ING-CC-0007 - Synagis (palivizumab)
- ING-CC-0011 - Ocrevus (ocrelizumab)
- ING-CC-0014 - Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
- ING-CC-0020 - Tysabri (natalizumab)
- ING-CC-0027 - Denosumab Agents
- ING-CC-0030 - Implantable and ER Buprenorphine Containing Agents
- ING-CC-0034 - Hereditary Angioedema Agents
- ING-CC-0036 - Naltrexone Implantable Pellets
- ING-CC-0100 - Istodax (romidepsin)
- ING-CC-0141 - Off-Label Drug and Approved Orphan Drug Use
- ING-CC-0144 - Lumoxiti (moxetumomab pasudotox-tdfk)
Revised clinical criteria effective October 1, 2020
(The following criteria were updated with new procedure and/or diagnosis codes.)
- ING-CC-0094 - Alimta (pemetrexed disodium)
- ING-CC-0100 - Istodax (romidepsin)
- ING-CC-0127 - Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- ING-CC-0140 - Zulresso (brexanolone)
- ING-CC-0160 - Vyepti (eptinezumab-jjmr)
- ING-CC-0161 - Sarclisa (isatuximab-irfc)
- ING-CC-0162 - Tepezza (teprotumumab-trbw)
- ING-CC-0163 - Durysta (bimatoprost implant)
- ING-CC-0165 - Trodelvy (sacituzumab govitecan)
New clinical criteria effective January 1, 2021
(The criteria below are new and may result in services previously covered now being considered either not medically necessary and/or investigational)
- ING-CC-0168 - Tecartus (brexucabtagene autoleucel)
- ING-CC-0170 - Uplizna (inebilizumab)
- ING-CC-0171 - Zepzelca (lurbinectedin)
- ING-CC-0175 - Proleukin (aldesleukin)
- ING-CC-0176 - Beleodaq (belinostat)
- ING-CC-0177 - Zilretta (triamcinolone acetonide extended-release)
- ING-CC-0178 - Synribo (omacetaxine mepesuccinate)
Revised clinical criteria effective January 1, 2021
(The following criteria listed below might result in services that were previously covered 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-0009 - Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
- ING-CC-0010 - Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- ING-CC-0015 - Infertility and HCG Agents
- ING-CC-0029 - Dupixent (dupilumab)
- ING-CC-0035 - Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0038 - Human Parathyroid Hormone Agents
- ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
- ING-CC-0044 - Exondys 51 (eteplirsen)
- ING-CC-0058 - Octreotide Agents
- ING-CC-0061 - GnRH Analogs for the Treatment of Non-Oncologic Indications
- ING-CC-0064 - Interleukin-1 Inhibitors
- ING-CC-0077 - Palynziq (pegvaliase-pqpz)
- ING-CC-0082 - Onpattro (patisiran)
- ING-CC-0094 - Alimta (pemetrexed disodium)
- ING-CC-0119 - Yervoy (ipilimumab)
- ING-CC-0125 - Opdivo (nivolumab)
- ING-CC-0139 - Evenity (romosozumab-aqqg)
- ING-CC-0152 - Vyondys 53 (golodirsen)
Effective with dates of service on and after October 1, 2020, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem updated the drug lists that support our commercial health plans. Updates include changes to drug tiers and the removal of medications from the formulary.
As certain brand and generic drugs will no longer be covered, providers are encouraged to determine if a covered alternative drug is appropriate for their patients whose current medication will no longer be covered. Communications to providers and their patients affected by the changes went out in early August.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To help ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions and other requirements, restrictions or limitations that apply to certain drugs, visit anthem.com/pharmacyinformation.
- To locate the commercial drug list, select ‘Click here to access your drug list’.
- To locate the Marketplace Select Formulary and pharmacy information, scroll down to ‘Select Drug Lists’, then select the applicable state’s drug list link.
The commercial and marketplace drug lists are reviewed and updates are posted to the website quarterly (the first of the month for January, April, July and October).
Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. This drug list is also reviewed and updated regularly as needed.
Effective October 1, 2020, Anthem will integrate community health workers (CHWs) used by GroundGame Health (GGH)* into our current care management program. Referrals into the program are completed via provider direct referrals or ad hoc referrals from the Anthem Case Management team. Provider direct referrals will include members with the following situations:
- Identified social determinants of health needs including, but not limited to:
- Living environment
- Transportation
- Food insecurity issues
- Financial issues
- Social isolation, etc.
- Hospital readmissions
- A readmission risk score of more than 24
GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. PCHP makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from Anthem, or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.
A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.
The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.
To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 866-739-6323 or email physicianreferral@preferredchp.com.
Patient360 is a real-time dashboard you can access through the Availity portal* that gives you a full 360° view of your Anthem and AMH Health, LLC patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.
What’s new: Medical providers now have the option to include feedback for Anthem and AMH Health patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.
Once you have completed all the required fields on the Availity portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.
Are you using Patient360 for the first time? You can easily access Patient360 on the Availity portal.
First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.
Once you have the Availity role assignment, navigate to Patient360 through the Availity portal by selecting the application on Anthem and AMH Health Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.
Do you need a job aid to help you get started?
The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.
- From the Availity home page, select Payer Spaces > health plan payer tile > Applications > Custom Learning Center
- Select Resources from the menu located on the upper left corner of the page
- (To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)
- Select Download to view and/or print the reference guide
On December 1, 2020, Anthem prior authorization (PA) requirements will change for certain codes. 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. See the attachment to this article for the additional codes that will require prior authorization effective December 1, 2020.
This is not a complete list of prior authorization requirements. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/medicareprovider > Login. Contracted and non-contracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.
On January 1, 2021, Anthem prior authorization (PA) requirements will change for certain codes. 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. See the attachment to this article for the additional codes that will require prior authorization effective January 1, 2021.
Not all prior authorization requirements are listed in the attachment. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/provider/medicare-advantage > Login. Contracted and non-contracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.
A key goal in our provider transparency initiative is to improve quality while managing health care costs. One of the ways we do that is by offering value-based programs including Freestanding Patient Centered Care (FPCC), Medicare Advantage Enhanced Personal Health Care Essentials, and so on (known as the Programs).
Value-based program providers (also known as payment innovation providers) in our programs receive quality, utilization and/or cost data, reports, and information about the health care providers (referral providers) to whom the providers may refer their Anthem and AMH Health, LLC patients. If a referral provider is higher quality and/or lower cost, this component of the Programs should result in the provider receiving more referrals from value-based program providers. The converse should be true if referral providers are lower quality and/or higher cost.
Providing this type of data to value-based program providers (including comparative cost information) helps them make more informed decisions about managing health care costs, maintain/improve quality of care and succeed under the terms of the Programs.
Additionally, employers and group health plans (or their representative/vendors) may also be given data about value-based program providers or referral providers to better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.
Upon request, Anthem and AMH Health will share the data used to make these quality/cost/utilization evaluations and will discuss it with referral providers, including any opportunities for improvement.
If you have questions or need support, contact the Provider Call Center.
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.
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