Effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works 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.

The expansion will require clinical appropriateness review for additional procedures related to Carelon Medical Benefits Management programs, including cardiology, radiation oncology, radiology, musculoskeletal, sleep, surgical, and additional outpatient services.

Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem for medical necessity determination. Anthem makes coverage determinations based on CMS guidance, including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Carelon Medical Benefits Management will continue to use criteria documented in the Medical Policies and Clinical Guidelines of Anthem listed in the table below. These clinical guidelines can be found at Availity.com.

Detailed prior authorization (PA) requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at Availity.com. Contracted and noncontracted care providers should call Provider Services at the phone number on the back of the member’s ID card for PA requirements.

Prior authorization review requirements

Carelon Medical Benefits Management will begin accepting PA requests on September 24, 2024, for dates of service October 1, 2024, and after. For procedures scheduled to begin on or after October 1, 2024, care providers must contact Carelon Medical Benefits Management to obtain PA for the non‑emergency modalities below. Refer to the clinical guidelines on the microsite resource pages for complete code lists.

To determine if PA is needed for a member on or after October 1, 2024, call Provider Services using the phone number on the back of the member’s ID card. Care providers using the interactive care reviewer (ICR) tool on Availity.com for PA requests on an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management (Note: ICR cannot accept PA requests for services administered by Carelon Medical Benefits Management).

How to place a review request

Care providers may place a PA request online to Carelon Medical Benefits Management by way of providerportal.com. ProviderPortal_SM is available 24/7, processing requests in real-time using clinical criteria.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, surgical, and programs, visit:

• Cardiovascular Solution | Carelon Insights
• Musculoskeletal (MSK) Solution | Carelon Insights (AIM)
• Sleep Solution | Sleep Healthcare | Carelon Insights
• Surgical Procedures Solution | Carelon Insights
• Radiation Oncology Solution | Carelon Insights

Our website helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQs.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

In collaboration with Availity, we’ve developed self-paced training for your organization’s administrators about how to update the Medical Attachment registration.

Care providers enrolled in the Medical Attachments applications on Availity Essentials can now take advantage of faster claims processing through Digital Request for Additional Information (Digital RFAI). Receive digital notifications faster when additional documents are needed to process member claims.

Availity administrators can use this link to view the training on demand for Digital Request for Additional Information: Pre-check for Administrators.

We have also developed an enhanced training session for associates responsible for sending attachments. This training walks through the Attachments Dashboard and many of the unique features that make the dashboard most efficient.

Use this link to register for the live trainings or to view the training on demand for Learn How to Submit Digital Requests for Additional Information (RFAI).

Register today!

• June 11, 2024, from 2:30 to 3:30 p.m. ET
• June 13, 2024, from 2:30 to 3:30 p.m. ET.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

The following Anthem’s Medical Policies and Clinical Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view Medical Policies and Clinical Utilization Management Guidelines, go to anthem.com > select Providers > select your state > under Provider Resources > select Policies, Guidelines & Manuals.

To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > select your state > under Claims > select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card.

To view medical policies and utilization management guidelines applicable to members enrolled in the Federal Employee Program^® (FEP), visit fepblue.org > Policies & Guidelines.

Below are the current Clinical Guidelines or Medical Policies we reviewed, and updates were approved.

* Denotes prior authorization required

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

• Behavioral Health Care (BHG):
  • The goal length of stay (GLOS) has been changed in two guidelines in the 28th edition of Behavioral Health Care.
• Inpatient & Surgical Care (ISC):
  • The goal length of stay (GLOS) has been changed in a total of 72 Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care. In medical Optimal Recovery Guidelines, the GLOS has been changed in 37 guidelines, and the GLOS has been changed in 35 surgical Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care.
• General Recovery Care (GRG):
  • Benchmark length of stay (BLOS) has been refined in the 28th edition of General Recovery Care.
• Recovery Facility Care (RFC):
  • A total of one guideline has been removed from the 28th edition of Recovery Facility Care.
• Chronic Care (CCG):
  • A total of 10 guidelines have been moved in the 28th edition of Chronic Care.

If you have questions, please contact the provider service number on the back of the member's ID card.

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive.

• Behavioral Health Care (BHG)
  • The goal length of stay (GLOS) has been changed in 2 guidelines in the 28th edition of Behavioral Health Care.
• Inpatient & Surgical Care (ISC)
  • The goal length of stay (GLOS) has been changed in a total of 72 Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care. In medical Optimal Recovery Guidelines, the GLOS has been changed in 37 guidelines and the GLOS has been changed in 35 surgical Optimal Recovery Guidelines, in the 28th edition of Inpatient & Surgical Care.
• General Recovery Care (GRG)
  • The benchmark length of stay (BLOS) has been refined in the 28th edition of General Recovery Care.
• Chronic Care (CCG)
  • A total of 10 guidelines have been moved in the 28th edition of Chronic Care.

For questions, please contact the provider service number on the back of the member's ID card.

Effective for dates of service on and after September 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.:

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access Carelon Medical Benefits Management’s ProviderPortal_SM directly at providerportal.com.
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access Carelon Medical Benefits Management via the Availity website at Availity.com.

If you have questions related to guidelines, contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after September 1, 2024, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management, Inc. guideline annual review process, these updates focus on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates

All post-acute care (PAC) guidelines — skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term acute care hospital (LTACH):

• Re-structured original guidelines into three separate, level of care-specific guidelines
• Updated background and definitions and refined several criteria to be more applicable to each guideline after re-structuring
• Removed most criteria pertaining to transfer between other levels of PAC
• Removed facility accessibility and health-related social needs (HRSN) criteria
• Removed requirement for physician referral
• Added sub-criteria to existing criteria in ongoing care regarding remaining therapeutic goals
• Added verbiage and examples for clarification of original intent or for more level of care-specific applicability

LTACH only:

• Refined criteria around need for hospice/palliative care consultation

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon Medical Benefits Management will begin receiving requests on May 29, 2024, for members whose anticipated discharge date is June 1, 2024, or after.

Providers are encouraged to request authorization using NexLync. Go to the Carelon Medical Benefits Management website to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.

To learn more about Carelon Medical Benefits Management and upcoming training webinars, visit https://providers.carelonmedicalbenefitsmanagement.com/postacute or email PACprovider_relations@carelon.com.

If you are unable to access/use any of the links or have other questions, call the Carelon Medical Benefits Management Provider Call Center at 833-431-0780 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday.

Effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works 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.

The continued migration will expand clinical appropriateness review for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, radiation oncology, radiology, sleep, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — Additional outpatient UM (utilization management) that will include some transportation (including ambulance) and fertility procedures as set forth below. Transportation may include emergency post-service reviews.

The Clinical UM Guidelines and Medical Policies adopted by Anthem for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 23, 2024, for dates of service on or after October 1, 2024.

Members included in the new program

Updates to Carelon Medical Benefits Management programs apply to select local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard^®, Medicare Advantage, Medicaid, Medicare Supplemental, or Federal Employee Program^® (FEP^®). For more information, please contact the phone number on the back of the member ID card.

Pre-service review requirements

For procedures that are scheduled to begin on or after October 1, 2024, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including, but not limited to, the following non-emergency modalities. Please refer to the Clinical Guidelines at anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.

Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.

To determine if prior authorization is needed for a member on or after October 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on Availity.com to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortal_SM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providerportal.com to register.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:

• Cardiovascular Solution | Carelon Insights
• Radiology Solution | Carelon Insights
• Sleep Solution | Sleep Healthcare | Carelon Insights
• Surgical Procedures Solution | Carelon Insights
• Radiation Oncology Solution | Carelon Insights

Our website at anthem.com helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQs. You can also contact your local network relations representative if you have any questions.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Medications are the primary intervention in treating and preventing disease. For most conditions, medications need to be taken 80% or more of the time to see an improvement in clinical outcomes.

Forty to fifty percent of patients are non-adherent to their medications for chronic conditions, leading to 100,000 preventable deaths and $100 to $300 billion in preventable medical costs per year.*

How can we prevent and close adherence gaps?

Be aware of contributing factors that influence non-adherence:

• Cognitive impairment
• Fear of side effects
• Too many medications
• History of non-adherence
• Lack of perceived benefit
• Confusion
• Transportation
• Cost

Implement a standardized process to identify patients with non-adherence:

• Ask about adherence at every appointment.
• Incorporate patient questionnaires or patient interviews using open-ended questions into existing workflows.
• Analyze non-adherence reporting or claims to identify patients.
• Leverage your electronic health record to identify patients at risk for non-adherence.

Be proactive: Tailor the solution to the patient’s needs or concerns:

• Simplify the medication regimen by considering once daily dosing.
• Always educate patients on benefits and risks of taking or not taking their medications.
• Leverage real-time prescription benefit to select lower cost and formulary medications during the electronic prescribing process.
• Consider home delivery (mail) and 90-day supply to prevent refill gaps, avoid long waits at the pharmacy, and minimize transportation barriers.

Consider medication non-adherence first as a reason when a patient’s condition is not under control.

Cardiovascular disease is the leading cause of death among people with diabetes. ¹ National guidelines continue to recommend statin therapy in all patients with diabetes between the ages of 40 and 75, regardless of low-density lipoprotein (LDL) level, to prevent development of cardiovascular disease:

• Reducing LDL-C levels by ~39 mg/dL with statin therapy can reduce heart disease and stroke mortality by 13%, regardless of the baseline LDL cholesterol levels.¹
• Nearly 60% of statin-eligible patients were never offered statin therapy by their doctor.² Moreover, 50% of adults in the United States who would benefit from statins are taking them.³
• Up to 34% of patients never fill the initial statin prescription (primary non-adherence).⁴
  
  

Statin Use in Patients with Diabetes (SUPD) is a CMS-adopted quality Star measure:

• The SUPD measure is defined as percent of Medicare Part D beneficiaries 40 to 75 years old who were dispensed at least two diabetes medication fills and received a statin medication fill during the measurement period.
• When assessing patients for appropriateness of statin therapy, also evaluate for potential measure exclusions.

Exclusions for the SUPD measure include:

• End stage renal disease.
• Hospice.
• Rhabdomyolysis or myopathy.
• Pregnancy/lactation.
• Cirrhosis.
• Pre-diabetes.
• Polycystic ovary syndrome.
• Fertility medication.

• Reassess patient every year to evaluate the appropriateness of acceptable exclusions.
• Exclusions require a submitted code each calendar year.

Best practices in initiating and improving statin adherence:

• Offer statin therapy to all patients ages 40 to 75 years old who have diabetes, regardless of LDL.
• Guidelines recommend moderate or high intensity statin depending on additional risks.
• Get patient buy-in: Ask patients what they know about statins. Address any fears or concerns and educate them on statin benefits:
  • Fear of and perceived side effects are the most common reasons for declining or discontinuing statin therapy.⁴
• Once a statin has been prescribed, follow up with patients to assess adherence.
• Be aware of best practices to evaluate patient reported muscle side effects and an implementation strategy for re-initiation.

View a video about statins here.

Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about:

• 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 the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner.