We’re making it even easier for you to schedule online appointments through the Appointment Scheduler App on Availity.  The Appointment Scheduler App gives you secure access to new appointment requests. You’ll also receive digital access to the member’s ID number, contact information and any special health information.

 

Appointment Scheduler App features include:

• Manage appointment requests
• Configure appointment availability
• Notifications for new visit requests on your Availity dashboard
• Members are automatically notified by text or email when appointments are confirmed

 

Administrators, administrator assistants and users with the role of “office staff” will have access to the Appointment Scheduler App.

 

To access Appointment Scheduler , log onto Availity.com and select Anthem from Payer Spaces. The Appointment Schedule App will be located in your Applications menu. To learn more about the new App, visit the Custom Learning Center in Availity for the Appointment Scheduler Application Reference Guide.

 

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Effective November 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will transition the clinical criteria for medical necessity review of computed tomography to detect coronary artery calcification to AIM imaging of the heart clinical appropriateness guideline. 

 

As part of this transition of clinical criteria, the following procedures will be subject to prior authorization at AIM: 

 

CPT code	Description
75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery calcium
S8092	Electron beam CT (also known as ultrafast CT, cine CT)

 

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com.

 

Additionally, you may access and download a copy of the current guideline here.

 

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Beginning with dates of service on or after November 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will update the Related Coding section to indicate no modifier override for the neurostimulator device when billed with the surgical code for the implantation of the neurostimulator device.

 

The code pairs listed below have been added the below pairs to the Related Coding Section:

• L8680 when reported with 63655
• L8679 when reported with 63650
• L8679 when reported with 63655
• L8687 when reported with 63650
• L8687 when reported with 63655

 

For more information about this policy, visit the Reimbursement Policy page at anthem.com.

 

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In our May Provider News, we announced a threshold increase for the itemized bill requirement for outpatient facility claims. This requirement will remain; however effective August 1, 2021, Anthem will remove the threshold amount from the policy language for outpatient facility claims and inpatient stay claims.

For more information about this policy, visit the Reimbursement Policy page at anthem.com.

 

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Beginning with dates of service on or after November 1, 2021, Anthem Blue Cross and Blue Shield (Anthem)’s current Telehealth policy will be renamed Virtual Visits. Anthem allows reimbursement for professional and facility Virtual Visits when interactive services occur between the member and the provider, when they are not in the same location, unless provider, state, or federal contracts and/or mandates indicate otherwise.  Reimbursement is allowed for professional and facility Virtual Visits rendered at the distant site via live audio visual services and for Remote Patient Monitoring. Services reported by a professional provider with a place of service Telehealth (02) will be eligible for non-office place of service reimbursement. In addition, facility Virtual Visits will be allowed for the originating site fee. The Related Coding section details the modifiers allowed for reimbursement.

 

For more information about this policy, visit the Reimbursement Policy page at anthem.com.

 

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Effective November 1, 2021, in order to help ensure our member’s security, the Blue Cross and Blue Shield Federal Employee Program (FEP_®) will be decommissioning the Utilization Management (UM) email address for processing eReviews, FEPE-Reviews@anthem.com.  As an alternative, FEP offers providers a secure online portal, Interactive Care Reviewer (ICR).

 

About the ICR portal

ICR is Anthem Blue Cross and Blue Shield (Anthem)’s innovative UM portal that allows providers, in addition to phone or fax, to submit prior authorization requests and to provide clinical documentation (including imaging) to support initial and continued stay reviews. This enables prior authorization requests and clinical information to be transmitted directly to UM staff.

 

Key features of the portal

• No cost electronic UM solution
• Instant access from any location at any time
• Create a UM preauthorization case and instantly submit it for review
• Attach clinical documents for review – no faxing required
• Check status of any case regardless of the method used to originally submit request
• Complete record of submissions and dispositions – all in one place
• Bi-directional communication

 

To submit prior authorization service requests electronically, register for use of ICR prior to November 1, 2021 on the Availity portal.

 

For more information on Anthem ICR, including training resources: https://www.anthem.com/provider/prior-authorization/interactive-care-reviewer/

 

Register for ICR via the Availity portal: https://www.availity.com/provider-portal-registration

 

Need help registering? View this video: How to Access Availity and Register

 

As a reminder, in addition to using ICR on the Availity portal, you can submit authorizations, to FEP UM by phone or fax:

• FEP UM precertification toll free #: 800-860-2156
• FEP UM precertification fax #: 800-732-8318
• FEP UM advance benefit determination fax #: 877-606-3807

 

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Effective with dates of service on or after August 1, 2021, providers treating members covered by Anthem Blue Cross and Blue Shield (Anthem) Commercial plans may be asked to consider voluntarily using adjusted body weight (AdjBW) dosing compared to actual body weight (ABW) dosing for immune globulin medications. The dose change using AdjBW will only be made if the member’s actual body weight is more than 20% of the ideal body weight (IBW).

 

Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization.

 

Reviews for the immune globulin medications will continue to be administered by IngenioRx_® as these will specifically target specialty non-oncology indications.

 

As part of the prior authorization process, providers may be asked the following questions:

• Whether the suggested use of AdjBW and change in dose is clinically acceptable
• Clinical reasoning if the dose change (using AdjBW) is not appropriate

 

Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

 

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Visit Pharmacy Information for Providers on 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 marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).

 

To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.

 

FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.

 

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Effective with dates of service on or after August 1, 2021, providers treating members covered by Anthem Blue Cross and Blue Shield (Anthem) Commercial plans may be asked to consider voluntarily reducing the requested dose to avoid vial wastage for select non-oncology specialty medications. The dose reduction suggestion will only be made if the originally requested dose is within 10% of the nearest whole vial.

 

Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization. 

 

Reviews for these specialty drugs will continue to be administered by IngenioRx_®.

 

As part of the prior authorization process, providers may be asked the following questions:

• Whether the suggested dose reduction is clinically acceptable
• Clinical reasoning if the dose reduction is not appropriate

 

Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

 

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Providers treating members covered by Anthem Blue Cross and Blue Shield (Anthem) plans will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications (see list below). Reviews for these oncology drugs will continue to be administered by AIM Specialty Health_® (AIM).

 

As part of the online prior authorization process, providers will be asked about the dosage of the medication being requested in pop-up questions:

• Whether or not the recommended dose reduction is acceptable
• If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning.

 

For prior authorization requests made outside of the online AIM Provider Portal (i.e. via phone or fax) the same questions will be asked by the registered nurse or medical director reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.

 

The dose reduction questions will appear only if the originally requested dose is within 10 percent of the nearest whole vial. This threshold is based on the current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) it is appropriate to consider dose rounding within 10 percent. Click here to view the HOPA recommendations.

 

The voluntary dose reduction program only applies to the specific oncology drugs listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

 

Note: In some plans “dose reduction to nearest whole vial” or another term “waste reduction” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “dose reduction to nearest whole vial” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “dose reduction (to nearest whole vial).”

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

 

Drug Name	HCPCS Code
Abraxane (paclitaxel protein-bound)	J9264
Actimmune (interferon gamma-1B)	J9216
Adcetris (brentuximab vedotin)	J9042
Alimta (pemetrexed)	J9305
Asparlas (calaspargase pegol-mknl)	J9118
Avastin (bevacizumab)	J9035
Bendeka (bendamustine)	J9034
Besponsa (inotuzumab ozogamicin)	J9229
Blincyto (blinatumomab)	J9039
Cyramza (ramucirumab)	J9308
Darzalex (daratumumab)	J9145
Doxorubicin liposomal	Q2050
Elzonris (tagraxofusp-erzs)	J9269
Empliciti (elotuzumab)	J9176
Enhertu (fam-trastuzumab deruxtecan-nxki)	J9358
Erbitux (cetuximab)	J9055
Erwinase (asparginase)	J9019
Ethyol (amifostine)	J0207
Granix (tbo-filgrastim)	J1447
Halaven (eribulin mesylate)	J9179
Herceptin (trastuzumab)	J9355
Herzuma (trastuzumab-pkrb)	Q5113
Imfinzi (durvalumab)	J9173
Istodax (romidepsin)	J9315
Ixempra (ixabepilone)	J9207
Jevtana (cabazitaxel)	J9043
Kadcyla (ado-trastuzumab emtansine)	J9354
Kanjinti (trastuzumab-anns)	Q5117
Keytruda (pembrolizumab)	J9271
Kyprolis (carfilzomib)	J9047
Lumoxiti (moxetumomab pasudotox-tdfk)	J9313
Mvasi (bevacizumab-awwb)	Q5107
Mylotarg (gemtuzumab ozogamicin)	J9203
Neupogen (filgrastim)	J1442
Ogivri (trastuzumab-dkst)	Q5114
Oncaspar (pegaspargase)	J9266
Ontruzant (trastuzumab-dttb)	Q5112
Opdivo (nivolumab)	J9299
Padcev (enfortumab vedotin-ejfv)	J9177
Polivy (polatuzumab vedotin-piiq)	J9309
Riabni (rituximab-arrx)	Q5123
Rituxan (rituximab)	J9312
Ruxience (rituximab-pvvr)	Q5119
Sarclisa (isatuximab-irfc)	J9227
Sylvant (siltuximab)	J2860
Trazimera (trastuzumab-qyyp)	Q5116
Treanda (bendamustine)	J9033
Truxima (rituximab-abbs)	Q5115
Vectibix (panitumumab)	J9303
Yervoy (ipilimumab)	J9228
Zaltrap (ziv-aflibercept)	J9400
Zirabev (bevacizumab-bvzr)	Q5118

 

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Prior authorization updates

 

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Access the Clinical Criteria information here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
**ING-CC-0196	J3490 J9999 J3590	Zynlonta
**ING-CC-0197	J3490 J3590 J9999	Jemperli
*ING-CC-0199	J3490 J3590 C9399	Empaveli

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Quantity limit updates

 

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

Access the Clinical Criteria information here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0199	J3490 J3590 C9399	Empaveli

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

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Effective with dates of service on and after October 1, 2021, 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 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.

 

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