 Provider News MissouriFebruary 2021 Anthem Provider News - MissouriAnthem will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the Provider Maintenance Form. Contact Provider Services if you have any questions.
In January we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.
In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:
- Medical Policies and Clinical Guidelines
- Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)
Steps to access the Authorization Lookup application through Availity Payer Spaces
Access to the tool does not require an Availity role assignment.
- Select Payer Spaces
- Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu
- Select the Applications tab
- Select the Authorization Rules Lookup tile
Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:
- Tax ID
- National Provider Identifier (NPI)
- Member ID and birth date
- Member’s Group number or Contract Code
(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)
- CPT/HCPCS code
Give this new tool a try and discover how much this will improve the efficiency of your authorization process.
Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal.
Find Care, the doctor finder and transparency tool in Anthem’s online directory, provides many Anthem members with the ability to search and compare cost and quality measures for in-network providers using the secure member portal at anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, name, or personalized match.
Beginning March 13, 2021, the personalized match sorting option will be available for searches by procedure type. This sorting option is based on algorithms which will use a combination of member and provider features to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions and demographics. The algorithm will use provider factors such as surgeon-facility pairing (an individual provider who performs a procedure at a specific facility), cost efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.
These member and provider features will be combined to generate a unique ranking of surgeon-facility pairings or facility providers for each member conducting the procedure search. Surgeon-facility pairings with the highest overall ranking within the search radius will be displayed first with other pairings displayed in descending order based on overall rank and proximity to the center of the search radius.
The personalized match methodology for specialty-based searches remains unchanged. Members continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology has no impact on member benefits.
- Providers may review a copy of the new sorting methodology which has been posted on Availity – our secure Web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Provider Procedure Search Methodology.pdf.
- If you have general questions about the Find Care tool or this new sorting option, please contact Provider Customer Service.
- If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors, you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.
Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions.
The following Anthem Blue Cross and Blue Shield medical polices will require prior authorization for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
NOTE *Precertification required
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Title
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Information
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Effective Date
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* GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
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• Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered Investigational and not medically necessary (INV&NMN) for all indications.
CPT PLA code 0203U (effective 10/01/2020) will be considered INV&NMN; also listed NOC codes 81479, 81599 considered NMN when specified as this test.
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5/1/2021
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* SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
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• Implantable peripheral nerve stimulation devices are considered INV&NMN for all indications including, but not limited to, treatment of acute and chronic pain
• Moved content addressing implantable devices (temporarily or permanently implanted) from DME.00011 to this new policy with no change in criteria.
Existing nonspecific codes 64555, 64575, 64590, C1767, C1778, C1787, L8679, L8680, L8683 for neurostimulator implantation and devices will be reviewed and considered INV&NMN for description of PNS systems for pain
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5/1/2021
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* CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
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This document addresses angiographic evaluation for dialysis access circuit dysfunction and treatment for stenotic or thrombosed arterio-venous grafts (AVG) or fistulas (AVF). This document does not address angiographic evaluation as a treatment for venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, or improving venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).
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5/1/2021
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A new facility reimbursement policy titled Emergency Room Transfers will be implemented beginning with dates of service on, or after May 1, 2021. The policy allows reimbursement for one emergency room visit when a patient is transferred between facilities operating under the same agreement, have the same tax identification number (TIN), or is under common ownership. The transferring facility will not be eligible for separate reimbursement.
For more information about this policy, view Anthem’s reimbursement policies online for your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
A new facility reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services will be implemented beginning with dates of service on, or after May 1, 2021. Anthem does not allow reimbursement for office evaluation and management services when reported on a CMS 1450 (UB-04) with revenue code 761 (treatment rooms). Modifiers will not override the edit.
For more information about this policy, view Anthem’s reimbursement policies online for your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
975-0221-PN-KY.MO Effective with dates of service on and after April 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.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.
Prior authorization updates
Effective for dates of service on and after May 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.
Click here to access the Clinical Criteria information.
Anthem Blue Cross and Blue Shield (Anthem)’s 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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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0183
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J3590
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Sogroya
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*ING-CC-0001
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J0886
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Injection, epoetin alfa (Procrit/Epogen)
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*ING-CC-0019
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J3489
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Reclast, Zometa
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* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Oncology use is managed by AIM.
Quantity Limit Updates
Effective for dates of service on and after May 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.
Click here to access the Clinical Criteria information.
Anthem Blue Cross and Blue Shield (Anthem)’s 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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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0019
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J3489
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Reclast, Zometa
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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.
On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (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 September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
Effective January 1, 2021, College of the Ozarks will offer a Medicare Preferred (PPO) Medicare Advantage Plan with Part D (MAPD) through Anthem Blue Cross and Blue Shield (Anthem). Retirees with Medicare Parts A and B are eligible to enroll in the MAPD plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. The MAPD plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as an annual routine physical exam, LiveHealth Online* and SilverSneakers®.*
The prefix on College of the Ozarks member ID cards will be ZMX. The cards will also show the College of the Ozarks name and National Access Plus icon.
Providers may submit claims electronically using the electronic payer ID for the Anthem plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Claims should not be filed with original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about College of the Ozarks member benefits or coverage.
Detailed prior authorization requirements also are available to contracted providers by accessing the Availity Portal* at availity.com.
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