 Provider News MaineSeptember 2022 Anthem Maine Provider NewsNotices 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:
- Reimbursement policy update: Modifier Rules – Professional
- Specialty pharmacy updates - September 2022
- Clinical criteria updates for specialty pharmacy
Register today for the Exploring the Intersection of Race and Disability forum hosted by Anthem and Motivo* for Anthem providers on September 21, 2022.
Anthem is committed to making healthcare simpler and reducing health disparities. We believe that continuing the discussion we started at our June 2022 event to deepen the conversation about the disability experience for people of is critically important. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.
Wednesday, September 21, 2022
4 to 5:30 p.m. ET
Please register for this event by visiting this link.
The Health Resources & Services Administration (HRSA) Women’s Preventive Services Guidelines recommend women receive at least one preventive care visit per year.
While many members may receive a standalone preventive care visit, well-women visits may also include pre-pregnancy, prenatal, postpartum, and interpregnancy visits. For members receiving pre-pregnancy, prenatal, postpartum, and/or interpregnancy care that is billed using a global maternity code (for example, CPT® 59400, 59510, 59610, 59618) or antepartum/postpartum codes (for example, CPT 59425, 59426, 59430), it is appropriate to submit a claim for a wellness visit (for example, CPT 99385, 99386, 99387, 99395, 99396, 99397) when recommended preventive care has been rendered for a member who has not received a wellness visit in the last year. This will help ensure recognition that recommended preventive services have been provided for our members.
Please note, wellness evaluation and management (E/M) codes should not be billed on the same day as global maternity or antepartum/postpartum codes. Providers should continue to verify eligibility and benefits for all members prior to rendering services.
Effective July 1, 2022, Anthem Blue Cross and Blue Shield recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Anthem contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims.
The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Anthem for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.
The following Anthem benefit plans are in scope for participation in HiH:
The following Anthem plans are out of scope for participation in HiH:
Note:
- Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Anthem suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
- Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
- Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
- Facility shall not bill Anthem or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
- Notify Anthem immediately through the utilization management nurse assigned to the HiH case when:
- An applicable member is admitted to the HiH program
- A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
- As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Anthem Agreement and/or as outlined in the applicable Anthem provider manual.
- We will continue to update billing guidance as these programs evolve.
As a reminder, when billing medical drug codes to Anthem Blue Cross and Blue Shield, include these three components:
- National Drug Code (NDC)
- Quantity
- Unit of measure
To prevent possible denial of the of the billed code, please ensure all three components are included in the claim.
Keeping your provider directory information current is key for members and your healthcare partners to engage with you seamlessly. Please review your information regularly and let us know if any of your information we show in our online directory has changed.
To update your information, use 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 Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
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. Help us keep our online provider directories current.
This communication applies to Anthem Blue Cross and Blue Shield’s Commercial program and AMH Health LLC’s Medicare Advantage program.
We are carefully monitoring the recent outbreak of monkeypox infections in the U.S. and are working to support our members and our network care providers with information to help you respond appropriately in the context of your patient population.
The best source of up-to-date information is at the Centers for Disease Control and Prevention which has a dedicated monkeypox page for healthcare professionals.
In addition to resources for care providers, the CDC has developed educational materials for the public, available for free download online.
FAQs
Who can become infected?
With this recent outbreak, monkeypox has spread through close, intimate contact with someone who has monkeypox. Many cases initially occurred in men who have sex with men. However, anyone can get monkeypox.
How dangerous is the disease?
Monkeypox virus belongs to poxvirus family and infection is rarely fatal. Patients whose immune system is compromised are most at risk for severe disease, along with children younger than 8 years old, pregnant and breastfeeding people, and people with a history of atopic dermatitis or other active skin conditions.
What are monkeypox symptoms?
Patients often have a characteristic rash (well-circumscribed, firm, or hard macules evolving to vesicles or pustules) on a single site on the body. Patients may also present with a fever and muscle aches. The rash may start in the genital and perianal areas. The lesions are painful when they initially emerge, but can become itchy as they heal, and then go away after two to four weeks. Symptoms can be similar or occur at the same time as sexually transmitted infections.
How does monkeypox spread?
Monkeypox does not spread easily between people without close contact. Person-to-person transmission is possible by skin-to-skin contact with body fluids or monkeypox sores, or respiratory droplets during prolonged face-to-face contact, and less likely through contaminated items such as bedding, clothing, or towels. Patients are contagious until the scabs heal and are replaced by new skin.
Is there a monkeypox vaccine?
Yes, although at the time of this writing, availability is limited. Smallpox and monkeypox vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox, and vaccination after a monkeypox exposure may help prevent the disease or make it less severe. You can access the CDC’s vaccination updates online.
How can monkeypox be treated?
There are no treatments specifically for monkeypox virus infections. However, antiviral drugs and vaccines developed to protect against smallpox may be used to prevent and treat monkeypox virus infections.
Do I need to report a case of suspected monkeypox?
Yes. Contact your state health department if you have a patient with monkeypox. They can help with testing and exposure precautions.
What are the behavioral health impacts of monkeypox?
Studies reporting psychiatric symptoms have indicated that the presence of anxiety, depression, or low mood is common among hospitalized patients with monkeypox infection. Care providers can help by listening with compassion, understanding underlying behavioral health concerns that may be heightened during isolation, and refer patients to the appropriate level of support following a monkeypox diagnosis.
3 things to do when you don’t find your claim in Claim Status
We appreciate the positive feedback you’ve shared about the new Claim Status Send Attachment feature. This enhancement to the attachment process enables you to submit an attachment directly to your claim on Availity.com by simply selecting the new Send Attachment button. We want to keep that positive momentum by answering your questions about those times when you are not able to find your claim in the Claim Status application using Availity Essentials. Here are a few suggestions:
- Double check your search information. Is the member information entered correctly? Many times, it is as simple as double checking the basic information needed to search for the claim.
- Do you have a claim number? If we’ve requested additional information in order to process your claim, the claim number will be included in the letter to you. Use this claim number to search for your claim.
- If you have located your claim, but the Send Attachment feature is not displayed, we have a solution for you:
- From the Claims & Payment tab select Attachments – New. This will take you to your Attachments Dashboard.
- From the Attachments Dashboard, select Send Attachment.
- From the drop down, select Medical Attachment.
- Complete the form and use the Add Attachment button to upload your files.
- Press Send Attachments and your documents will be attached to your claim.
Claims attachment learning opportunities
In collaboration with Availity Essentials, we’ve made it easy for you to learn when it is convenient for you. Through this on-demand webinar, learn how to submit claim attachments through Claim Status. Use this link to access the course. If live webinars fit into your schedule, use this link to sign up today.
Beginning with date of services on or after December 1, 2022, modifier FT is only allowed for reimbursement on critical care codes 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476.
Modifier FT was created by the Centers for Medicare & Medicaid Services (CMS) and is included in our Claims Impacting Adjudication list located in the Related Coding section of our Modifier Rules policy (professional).
Modifier FT is defined as an unrelated evaluation and management (E/M) visit during a postoperative period, or on the same day as a procedure or another E/M visit. (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated).
For specific policy details, visit the reimbursement policy page at anthem.com.
In the December 2021 edition of Provider News, we announced that a new commercial reimbursement policy titled Modifier 66 Surgical Teams – Professional would be effective for dates of service on or after March 1, 2022. The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
Modifier 66: Surgical Teams – Professional: Under this reimbursement policy, Anthem allows the procedures eligible for surgical teams when billed with modifier 66.
Anthem follows the CMS MPFS Team Surgery payment indicators and will allow services requiring team surgery billed with CMS MPFS payment indicator ‘1’ (sometimes) and ‘2’ (always) and will deny services billed with the indicator ‘0’ (never) and ‘9’ (not applicable).
For specific policy details, visit the reimbursement policy page at anthem.com.
In the December 2021 edition of Provider News, we announced that an update to our reimbursement policy titled Assistant at Surgery – Professional effective for dates of service on or after March 1, 2022. The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
This policy follows the Centers for Medicare & Medicaid Services (CMS) guidelines for the codes designated as ‘MPFS Assistant Surgery payment indicator ‘2’ “Always” requiring an assistant surgeon. Codes identified with MPFS Assistant Surgery payment indicators ‘0’, ‘1’, and ‘9’ are not allowed for reimbursement.
For specific policy details, visit the reimbursement policy page at anthem.com.
Effective October 1, 2022, Anthem and AIM Specialty Health®* (AIM), a separate specialty benefits management company, will launch a new Back Pain Management Program for fully insured members, as further outlined below.
Who is AIM?
Anthem has an existing relationship with AIM in the administration of other programs. Anthem is excited to expand this relationship to include additional services. AIM works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.
What is the Back Pain Management Program?
In pursuit of the commitment to improve healthcare quality and costs, we have created a new voluntary Back Pain Management Program to help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.
The program will be utilizing predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.
Our member engagement process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors.
- Risk stratification to ensure the appropriate level of support is provided.
- Targeted outreach to members through our digital engagement platform, email, and calls.
- Customized education and support of provider treatments based on member’s specific needs.
- Education and support of services such as behavioral health as appropriate.
Who is included in this new program?
All fully insured members currently participating in AIM and Anthem programs are included.
The following groups are excluded: Self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP).
The AIM Back Pain Program microsite helps you learn more and access helpful information and tools such as program information and FAQs.
We value your participation in our network and look forward to working with you to help improve the health of our members.
The Blue Cross and Blue Shield Service Benefit Plan, also known as the Federal Employee Program, FEP, is now requiring new information on claims that are required by OBRA93 law to be priced at the Medicare allowance. Members that are over 64 years old and do not have Medicare Part B coverage fall under the OBRA93 law for Medicare pricing. In order for us to obtain the Medicare pricing, the CMS 1500 claim must have a rendering provider ID submitted on the claim. Claims submitted without the rendering provider ID will deny with the following message on the remit and require the provider to resubmit with this required field.
Remit message: 339 NEED PROVIDER NAME & NPI IN ORDER TO DETERMINE MEDICARE FEE SCHEDULE
This claim submission requirement applies to Federal employee member claims only. An FEP member can be identified with an ID number beginning with R followed by 8 digits (for example, Rxxxxxxxx).
If you have any questions, please contact FEP Customer Service at CT 800-438-5356 ME 800-722-0203 NH 800-852-3316.
Specialty pharmacy updates for 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 December 1, 2022, 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-0217+
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Amvuttra™ (vutrisiran)
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J3490, J3590
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ING-CC-0218+
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Xipere® (triamcinolone acetonide injectable suspension)
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J3299
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Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on and after December 1, 2022, 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.
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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-0217+
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Amvuttra (vutrisiran)
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J3490, J3590
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ING-CC-0218+
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Xipere (triamcinolone acetonide injectable suspension)
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J3299
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The following clinical criteria documents were endorsed at the June 23, 2022, clinical criteria meeting. Visit our website to access the clinical criteria information.
New clinical criteria effective July 6, 2022
The following Clinical Criteria is new:
- ING-CC-0217 Amvuttra (vutrisiran)
Revised clinical criteria effective July 25, 2022
The following Clinical Criteria were revised to expand medical necessity indications or criteria:
- ING-CC-0015 Infertility and HCG Agents
- ING-CC-0041 Complement Inhibitors
- ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
- ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0150 Kymriah (tisagenlecleucel)
Revised clinical criteria effective July 25, 2022
The following Clinical Criteria were reviewed with no significant change to the medical necessity indications or criteria:
- ING-CC-0031 Intravitreal Corticosteroid Implants
- ING-CC-0049 Radicava (edaravone)
- ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
- ING-CC-0076 Nulojix (belatacept)
- ING-CC-0077 Palynziq (pegvaliase-pqpz)
- ING-CC-0136 Drug Dosage, Frequency, and Route of Administration
- ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use
- ING-CC-0163 Durysta (bimatoprost implant)
- ING-CC-0208 Adbry (tralokinumab)
New clinical criteria effective December 1, 2022
The following Clinical Criteria is new:
- ING-CC-0218 Xipere (triamcinolone acetonide injectable suspension) *
Revised clinical criteria effective December 1, 2022
The following Clinical Criteria was revised and might result in services that were previously covered but may now be found to be not medically necessary:
- ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications*
Effective with dates of service on and after October 1, 2022, and in accordance with the IngenioRx* Pharmacy and Therapeutics (P&T) process, Anthem will update its drug lists that support Commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
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.
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on www.Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are three options for submitting attachments:
- Through the attachments dashboard inbox:
- From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
- Through the 275 attachment:
- Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
- Through the Availity.com application:
- From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
If you submit your claim through the Availity application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
On December 1, 2022, AMH Health, LLC. prior authorization (PA) requirements will change for the following code. 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. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code:
L6715 — Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement
Not all PA requirements are listed here. Detailed PA requirements are available to providers on the provider website at https://www.anthem.com/provider/news/archives/?cnslocale=en_US_co&category=medicareadvantage or by accessing Availity* at https://availity.com.
Providers may also call Provider Services for assistance with PA requirements by referencing the number on the back of the patient’s member ID card.
The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for AMH Health, LLC. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.
For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://www.anthem.com/medicareprovider.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug 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.
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HCPCS or CPT® codes
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Medicare Part B drugs
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J0172
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Aduhelm (aducanumab-avwa)
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Effective for dates of service on and after November 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.
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HCPCS or CPT® codes
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Medicare part B drugs
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C9098
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Carvykti (ciltacabtagene autoleucel)
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J3490
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Carvykti (ciltacabtagene autoleucel)
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J3590
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Carvykti (ciltacabtagene autoleucel)
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What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Provider Experience associate or call the number on the back of your patient’s AMH Health, LLC. member ID card.
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