 Provider News MaineOctober 2022 Provider Newsletter – MaineNotices 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:
- Precertification list changes effective January 1, 2023
- Clinical Criteria updates for specialty pharmacy
- Specialty pharmacy updates - October 2022
- Reimbursement policy update: Multiple and Bilateral Surgery Processing – Professional
The State of Maine Health Plan has contracted with Carrum Health to approve all knee and hip replacement surgeries at the Carrum Health Center of Excellence provider, Spectrum. Beginning with dates of service on and after July 1, 2022, State of Maine members must go through the Carrum Health program for the following knee and hip services: 27447, 27446, 27125, 27130, DRG 469, DRG 470.
Prior authorization is required for these services. If prior authorization is not granted and a member does not receive approval through Carrum Health, claims submitted to Anthem for the services will be denied. Information about limited exceptions may be obtained through Carrum Health.
Please direct your patients to Carrum for approval at 888-855-7806 or visit my.carrumhealth.com/StateOfMaine for more information.
The State of Maine Health Plan is also implementing the AIM Clinical Review Program for Musculoskeletal Services.
We are asking you to review your online provider directory information on a regular basis to ensure it is correct. Access your information by visiting www.anthem.com, select For Providers, then choose Go To Providers Overview, select Find Care.
Submit updates and corrections to your directory information using our online Provider Maintenance Form. 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.
Once you submit the form, we will send you an email acknowledging receipt of your request.
The Consolidated Appropriations Act (CAA) contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. By reviewing your information regularly, you can help us ensure your online provider directory information is current.
The National Accounts 2023 Pre-certification list has been published. See the attached PDF for the updates. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.
The precertification list will be updated effective January 1, 2023. See the attached PDF for the updates.
To obtain precertification, providers can access Availity* at www.availity.com or call our Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.
Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.
Care providers are a trusted resource for members when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.
Some care providers may have seen a message on their provider Explanation of Benefits (EOB) stating that Anthem does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOB message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.
To aid in processing claims for the monkeypox and smallpox vaccine products, care providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:
- Product code (90611 or 90622)
- Applicable ICD-10-CM diagnosis code
- Administration code
More detail on codes and cost-sharing
Providers are encouraged to use:
- Product code 90611 for smallpox and monkeypox vaccine.
- Product code 90622 for vaccinia (smallpox) virus vaccine.
- Code 87593 for laboratory testing.
When billing the monkeypox and smallpox vaccine products, care providers should submit those codes with a $0.01 charge.
Cost-sharing for the vaccine is waived.
If you have any questions, contact the Provider Service number on the back of the member’s ID card. You can read more information on monkeypox here.
Background: We continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. Provider performance can vary widely in relation to efficiency, quality, and member experience. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables. Beginning January 1, 2023, we added a new sorting option on the FindCare tool for members to leverage when they are searching for Non-Primary Specialty Care Providers. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers are listed in order of their total score, though no individual scores will appear within the tool or be visible to Medicare covered patients. The personalized match algorithm is based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options are still available on FindCare as members should consider a variety of factors when making decisions for choosing a Non-Primary Specialty Care Provider to manage their care. Providers can view specific reporting on Availity Essentials, our secure web-based provider tool. When a provider visits the Contact Us section of Availity Essentials, they are able to select Personalized Match Phase 1, and there are the three following drop down options: 1) General Program Inquires, 2) Request a copy of your Provider Performance Scorecard, 3) Provider Performance Scorecard inquiries. The provider can fill out the required fields and this inquiry will then be routed to our VBP Operational Support team who will respond. This FAQ is designed to assist the call center when receiving inquiries from providers regarding Personalized Match Phase 1. A Medicare newsletter was published on November 1, 2022, that directs providers to Availity Essentials if they have any additional questions, would like to request a copy of their Provider Performance Scorecard, or have any other questions regarding their Provider Performance Scorecard. Additionally, Availity Essentials also contains an FAQ designed specifically for providers, in addition to a methodology document that describes the scoring system used to rank providers with quality and efficiency performance. If the call center is unable to satisfy a provider’s inquiry regarding Personalized Match Phase 1, please refer the provider to Availity Essentials. Personalized Match Phase 1 — FAQ Why are we implementing this Personalized Match Phase 1 program? We strive to make healthcare simpler, more affordable, and more accessible, and one of the ways to help achieve that goal is to ensure that consumers are connected with care providers who have strong track records of delivering quality care. When will this change be made to FindCare? Beginning on November 10, 2023, we will upgrade the online FindCare tool for Medicare members with a new sorting option called Personalized Match Phase 1, to match members with providers who perform well in efficiency and quality metrics within a certain geographical distance. Will the Personalized Match Phase 1 be a default option on FindCare? Yes, the new sorting option will be the default for members who search Medicare FindCare. How can providers obtain a copy of their Provider Performance Scorecard used for Personalized Match Phase? Providers will be able to view specific reporting on Availity Essentials, our secure web-based provider tool. When a provider visits the Contact Us section of Availity Essentials, they will be able to select Personalized Match Phase 1, and there will be the three following dropdown options: 1) General Program Inquires, 2) Request a copy of your Provider Performance Scorecard, 3) Provider Performance Scorecard inquiries. The provider will fill out the required fields and this inquiry will be routed to our VBS Ops team who will respond. Can you provide more information about the differences between the current Commercial Personalized Match and the Medicare Match Phase 1 Program? We currently offer Personalized Match to our consumer members. Personalized Match seeks to match members with documented health conditions with a provider who has a proven track record in closing gaps in care. For example, if a member who has been given a diagnosis of diabetes conducts a search, they will be matched with a provider whose patients consistently receive recommended A1c tests; a member who is a 60-year-old male would receive a different Personalized Match than a consumer who is a 30-year-old female. The goal is to move to this full Personalized Match solution in Medicare in the future. Personalized Match Phase 1 only analyzes providers’ quality and efficiency performance for generating the sort order. Is there a methodology document providers can view? Yes, providers may review a copy of the new sorting methodology which has been posted on Availity Essentials. Can providers submit an inquiry if they have questions or concerns about their score? Yes, if providers have general questions regarding this new sorting option, they should submit an inquiry via the web on Availity Essentials. If providers would like information about scoring used for this sorting option or to request reconsideration of a score, providers should submit an inquiry on Availity Essentials. How will this change affect patients? This change is part of a greater effort at Amerigroup to help improve access to high quality, affordable healthcare, which is essential to our customers. MEAMH-CR-032291-23-CPN32286 Now open for learning!
Understanding how to use the many time saving applications on Availity Essentials* is important to working together digitally. Anthem Blue Cross and Blue Shield has developed a learning place just for that purpose — the Provider Learning Hub.
Using the Provider Learning Hub available from https://www.anthem.com/provider is the easiest and quickest way to access courses and learning guides about claim submission, attachments and status, eligibility and benefits, and more.
These new and improved learning experiences apply to Availity Essentials and electronic data interchange (EDI) transactions:
- Visit the Provider Learning Hub for short, easy-to-follow training videos with supporting resources — no username and password required.
- Handy filtering options make it easy to find what you are looking for.
- The Favorites folder lets you save courses for easy access later.
- Register once and on future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today!
Access the Provider Learning Hub today using this link or from https://www.anthem.com/provider under Important Announcements on the home page.
Beginning with dates of service on or after January 1, 2023, Anthem Blue Cross and Blue Shield will update the Related Coding section of the policy with the following:
- Added CPT code 43497 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent
For specific policy details, visit the reimbursement policy page at anthem.com.
Effective as of July 27, 2022, Anthem Blue Cross and Blue Shield combined the Three-Dimensional (3D) Radiology Services- Facility and Three-Dimensional (3D) Radiology Services - Professional policies into a single policy. The Three-Dimensional (3D) Radiology Services - Professional policy was updated to include the facility-specific language from the facility policy, and the title was changed to Three-Dimensional (3D) Radiology Services – Professional and Facility. As a result, the Three-Dimensional (3D) Radiology Services - Facility policy will be retired.
For specific policy details, visit the reimbursement policy page at anthem.com provider website.
Effective July 8, 2022, Federal Employee Program (FEP) for Anthem Blue Cross and Blue Shield (Anthem) began participating in a real-time provider chat option through Availity Essentials. The secure portal allows providers to seek real-time answers to questions about prior authorization, precertification requirements, status check, and more.
Currently, only Missouri and Georgia providers can access the chat capability for Federal members. Chat is available from 8 a.m. to 7 p.m. ET through the secure provider website found at www.availity.com. Select Payer Spaces, Anthem, and access the chat through Chat with Payer.
Chat is one example of how FEP is using digital technology to improve the health care experience with the goal of saving valuable time.
With the success of the real-time chat option for Federal members, Anthem is implementing additional states ranging in dates from October 2022 through the first quarter of 2023.
Visit the Drug Lists page on www.anthem.com 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
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The Commercial and Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
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.
Inclusion of the National Drug Code on your claim will help expedite claim processing of drugs billed with a not otherwise classified code.
Step therapy updates
Effective for dates of service on and after January 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.
Please note that infliximab agents are subject to step therapy today, and this is to notify of the changes in the preferred and nonpreferred products. Inflectra will become non-preferred and Avsola will become preferred as of January 1, 2023.
Access our Clinical Criteria** to view the complete information for these step therapy updates.
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Clinical Criteria
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Status
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Drug
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HCPCS or CPT® code
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ING-CC-0062*
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Preferred
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Remicade
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J1745
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ING-CC-0062
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Preferred
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Infliximab Unbranded
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J1745
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ING-CC-0062
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Preferred
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Avsola
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Q5121
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ING-CC-0062
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Nonpreferred
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Inflectra
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Q5103
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ING-CC-0062
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Nonpreferred
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Renflexis
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Q5104
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* The applicable Clinical Criteria document is attached to this article in PDF format.
ATTACHMENTS (available on web): ING-CC-0062.pdf (pdf - 0.47mb) The following Clinical Criteria documents were endorsed at the August 19, 2022, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.
Revised Clinical Criteria effective August 30, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
Revised Clinical Criteria effective August 30, 2022
The following Clinical Criteria was reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0007 Synagis (palivizumab)
Revised Clinical Criteria effective September 19, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0100 Istodax (romidepsin)
- ING-CC-0104 Levoleucovorin Agents
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0140 Zulresso (brexanolone)
- ING-CC-0142 Somatuline Depot (lanreotide)
- ING-CC-0180 Monjuvi (tafasitamab-cxix)
- ING-CC-0182 Iron Agents
- ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
- ING-CC-0188 Imcivree (setmelanotide)
- ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
- ING-CC-0216 Opdualag (nivolumab and relatlimab-rmbw)
Revised Clinical Criteria effective September 19, 2022
The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0001 Erythropoiesis Stimulating Agents
- ING-CC-0004 Repository Corticotropin Injection
- ING-CC-0008 Subcutaneous Hormonal Implants
- ING-CC-0009 Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis
- ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- 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-0036 Naltrexone Implantable Pellets
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0044 Exondys 51 (eteplirsen)
- ING-CC-0139 Evenity (romosozumab-aqqg)
- ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)
- ING-CC-0152 Vyondys 53 (golodirsen)
- ING-CC-0156 Reblozyl (luspatercept)
- ING-CC-0171 Zepzelca (lurbinectedin)
- ING-CC-0172 Viltepso (viltolarsen)
- ING-CC-0174 Kesimpta (ofatumumab)
- ING-CC-0179 Blenrep (belantamab mafodotin-blmf)
- ING-CC-0189 Amondys 45 (casimersen)
- ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
- ING-CC-0193 Evkeeza (evinacumab)
- ING-CC-0197 Jemperli (dostarlimab-gxly)
- ING-CC-0200 Aduhelm (aducanumab-avwa)
- ING-CC-0202 Saphnelo (anifrolumab-fnia)
- ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
- ING-CC-0208 Adbry (tralokinumab)
- ING-CC-0209 Leqvio (inclisiran)
- ING-CC-0217 Amvuttra (vutrisiran)
Revised Clinical Criteria effective January 1, 2023
The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:
- ING-CC-0002 Colony Stimulating Factor Agents*
- ING-CC-0028 Benlysta (belimumab)*
- ING-CC-0029 Dupixent (dupilumab)*
- ING-CC-0034 Hereditary Angioedema Agents*
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)*
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23*
- ING-CC-0058 Octreotide Agents*
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications*
- ING-CC-0082 Onpattro (patisiran)*
- ING-CC-0142 Somatuline Depot (lanreotide)*
- ING-CC-0176 Beleodaq (belinostat)*
- ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)*
New Clinical Criteria effective January 1, 2023
The following Clinical Criteria is new:
- ING-CC-0219 Korsuva (difelikefalin acetate)*
* The applicable policy is attached to this article in PDF format.
This communication applies to the Anthem Blue Cross and Blue Shield (Anthem) Commercial programs and AMH Health, LLC. Medicare Advantage programs.
Our pharmacy benefit management partner, IngenioRx,* will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.
This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.
If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:
- IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
- IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.
These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.
When e-prescribing orders to the mail and specialty pharmacies:
- Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
- If searching by NPI (National Provider Identifier), the NPI will not change.
In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.
Keeping you well informed is essential and remains our top priority. We will continue to provide updates prior to January and throughout 2023.
Effective for dates of service on and after October 1, 2022, updated step criteria for immunoglobulins found in Clinical Criteria document ING-CC-0003 has been implemented. The preferred product list is being expanded. Please refer to the Clinical Criteria page for more information.
(Policy 21-001, effective 01/01/2022)
In the October 2021 edition of the provider newsletter, we announced that a new reimbursement policy titled Sexually Transmitted Infections Testing — Professional would be effective for dates of service on or after January 1, 2022. We have made a decision to retract this reimbursement policy.
If you have any questions, contact your Provider Experience associate or visit the Contact Us page on our provider website (https://www.anthem.com/medicareprovider) for up-to-date contact information.
The attached FAQ communication is designed to provide general guidance for questions related to Medicare telehealth services during the Coronavirus (COVID-19) Public Health Emergency (PHE). The PHE is ongoing and ever evolving; therefore, AMH Health, LLC wants to support accurate and up-to-date information around legal and regulatory changes that may impact healthcare.
This FAQ is for informational purposes only and is intended to provide guidance regarding the changing landscape of Medicare telehealth. This guidance is not all-inclusive; it is intended to address frequently asked questions and common Medicare telehealth topics. The content included herein is not intended to be a substitute for the provisions of applicable statutes or regulations or other relevant guidance issued by CMS, as those items are subject to change from time-to-time.
Care providers are a trusted resource for members when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.
Some care providers may have seen a message on their provider Explanation of Benefits (EOB) stating that AMH Health, LLC does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOB message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.
To aid in processing claims for the monkeypox and smallpox vaccine products, care providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:
- Product code (90611 or 90622)
- Applicable ICD-10-CM diagnosis code
- Administration code
More detail on codes and cost-sharing
Providers are encouraged to use:
- Product code 90611 for smallpox and monkeypox vaccine.
- Product code 90622 for vaccinia (smallpox) virus vaccine.
- Code 87593 for laboratory testing.
When billing the monkeypox and smallpox vaccine products, care providers should submit those codes with a $0.01 charge.
Cost-sharing for the vaccine is waived.
If you have any questions, contact the Provider Service number on the back of the member’s ID card. You can read more information on monkeypox here.
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