 Provider News MissouriOctober 2018 Anthem Missouri Provider NewsletterProvider Manual Update – Requested Medical Records Submission Functionality
Anthem Blue Cross and Blue Shield (Anthem) recently updated the Claim Inquiry/Adjustment Filing Tips section of our online Provider Manual. The update includes information on functionality to submit medical records requested by Anthem via Availity that was not available when the 2018 Provider Manual was originally posted. More detailed information on this functionality can be found in the August 2018 Network Update Newsletter. The updated manual is available on our public provider website at anthem.com. Select Providers under Partners in Health. On the Provider landing page, choose Find Resources for Your State and choose Missouri. On the Provider home page, choose Communications, then Publications.
Continuing to build on the initial launch of the new public provider pages, Anthem Blue Cross and Blue Shield (Anthem) recently released a brand new, redesigned landing page for Provider Resources. The most recent release also includes a new Communications page with a clear and concise access point for Newsletters and eUpdates, as pictured below.
This October, anthem.com will be introducing exciting changes to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for manuals and an improved, streamlined experience for Reimbursement Policies.
We will continue to keep you informed on upcoming changes to the public provider site as we progress toward streamlining our web platform and other business processes.
Anthem has partnered with Availity to operate and service the entry point for all EDI submissions to Anthem, otherwise known as the EDI Gateway.
Who is Availity?
Most of you know Availity as web portal or claims clearinghouse, but they are much more. Availity is also an intelligent EDI Gateway for multiple vendors and will be the EDI connection for all Anthem Inc. and its affiliates.
If you currently use a clearinghouse, billing company or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.
How are you submitting EDI transactions today?
- If you currently transmit your EDI Submissions using a clearinghouse or Billing Company, you should contact your clearinghouse to confirm your EDI submission path has not changed.
- If you are notified of any potential impacts with connectivity, workflow or financial, please know there is no cost alternate submission options available with Availity.
- If you currently submit directly to Anthem and already have an Availity login for the portal, you can use that same login for your EDI services.
- Please visit https://apps.availity.com/web/welcome/#/anthem to learn more.
How can you directly transmit EDI submission to Availity?
Below are the different ways you can submit direct EDI transactions to Availity:
- Submit transaction files through FTP - If you work with a practice management system, health information system, or other automated system that supports an FTP connection, you can securely upload EDI transactions to the Availity FTP site where they are automatically picked up by Availity and submitted to Anthem
- Submit transaction files through the Availity Portal - If you have batch files of EDI transactions that you need to process and you choose not to use the Availity FTP site, you can manually upload the batch files through the Availity Portal.
- Submit transactions through manual data entry in the Availity Portal - The Availity Portal makes it easy to submit transactions, such as eligibility and benefits inquiries or claims, by entering data into our user-friendly web forms.
What are your next steps?
- It may take time to work with your clearinghouse or billing company, so please take action now to help ensure continuity of your EDI transactions.
- If you choose to submit direct, we recommend that you register with Availity for your EDI transmissions and begin migrating your volume by the end of 2018 by visiting this URL- https://apps.availity.com/web/welcome/#/anthem
- The EDI transactions include the 837, 835 and 27X (eligibility and claim status).
- Availity will be working directly with your Clearinghouse, Billing Companies or your organization if you choose to submit directly.
We look forward to delivering a smooth transition to the Availity EDI Gateway. If you have any questions please contact Availity Client Services at 1-800-Availity (1-800-282-4548) Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time. Great news! Anthem, Inc. and our affiliates now use Availity as our designated EDI service. If you currently use a clearinghouse, billing company, or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.
Check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session. During this fast paced hour, learn how to:
- Understand Availity’s EDI Gateway and Clearinghouse workflow for 837, 270/271, 276/277, and 835 transactions.
- Use the Availity Portal to manage file transfers, set up EDI reporting preferences, manage your FTP account, and more.
- Enroll for and manage 835 ERA delivery with Availity.
- Access and navigate the Availity EDI Guide.
- and more….
Upcoming Sessions
Currently scheduled upcoming sessions include:
- October 29, 2018, 1:00 p.m. – 2:00 p.m. ET
- November 7, 2018, 11:00 a.m. – 12:00 p.m. ET
Enroll
- Log in to the Availity Portal.
- Select Help and Training > Get Trained.
- In the Availity Learning Center (ALC) Catalog, select Sessions.
- Scroll Your Calendar to find and enroll for a live session.
Can’t make it?
We’ve got you covered with a recording of a previous live session. In the ALC, search the Catalog by keyword (song) and enroll for the on-demand option.
Need Help?
Email training@availity.com if you have issues enrolling for a live webinar.
The Availity Education and Reference Center (ERC) offers the Communication & Education section where you can find training materials, important policy information, commonly used forms and reference guides on Anthem’s proprietary tools. When you visit the ERC, you can efficiently navigate to all available electronic resources using only the Availity Portal.
The Communication and Education section includes two new categories to help make it easier for you to find what you need: Payer Spaces and Interactive Care Reviewer.
With an Availity log in you can easily view any new content added to the ERC. There is no additional role assignment needed.
Find the ERC on the Availity Portal under Payer Spaces / Anthem / Applications. If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your Favorites.
The Special Investigations Unit (SIU) is tasked to conduct investigations involving allegations of fraud, waste and abuse, to work with our providers to resolve billing practice issues in order to reduce or eliminate future payment issues, and, where appropriate, to recover overpayments.
As part of Anthem’s role to safeguard our members and provide relevant information to providers we are relaying the following recent Food and Drug Administration (FDA) Warning Letters:
Estring - On June 19, 2018 the Food and Drug Administration issued a letter of warning to Pfizer for “false or misleading” promotional materials related to ESTRING® (estradiol vaginal ring). According to the FDA the posted “… video is especially concerning from a public health perspective because it fails to include any risk information about Estring, which is a drug that bears a boxed warning due to several serious, life-threatening risks, including endometrial cancer, breast cancer, and cardiovascular disorders, as well as numerous contraindications and warnings. The video thus creates a misleading impression about the safety and efficacy of Estring”.
Xtampza ER –-On February 9, 2018 the Food and Drug Administration issued a letter of warning to Collegium Pharmaceuticals for publicly providing false or misleading representations regarding Xtampza (oxycodone) ER because it “fails to adequately communicate information about the serious risks associated with Xtampza ER use”.
Further details regarding these Warning Letters from the FDA can be obtained from the FDA website:
We have completed the HEDIS data collection for 2018 and want to thank all of our provider offices and their staff who assisted us. Your collaboration in this process allows us to strive for the best HEDIS results possible.
This is the seventh year for our incentive program to acknowledge some of our providers who either responded in a timely manner or went “Above and Beyond” to help make our HEDIS data collection successful. Any practices that responded within five business days of our initial request or who went out of their way by taking additional steps to help us with data collection were entered in a drawing to receive a gift. We are pleased to announce that our incentive winners are as follows:
HEDIS Drawing Winners
- Crown Vision Center
- Family Clinic
- Freeman Lamar Family
- Gateway Cardiology PC
- Jordan Creek Nursing and Rehab
Above and Beyond Winners
- Betty Jean Kerr Peoples Health Center
- Jefferson City Medical Group PC
Our HEDIS results reflect the care you provide to our members. Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.
An overview of our HEDIS rates will be published in the 4th quarter provider newsletter. In addition more information on HEDIS can be found by visiting the provider portal at: www.anthem.com and select Provider, then Missouri, then Health & Wellness, then Quality Improvement and Standards, then HEDIS Information.
Thanks again to all of our provider offices and their staff for assisting us in collecting HEDIS data. We look forward to working with you next HEDIS season!
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions. Anthem Blue Cross and Blue Shield (Anthem) offers a new online learning course, What Matters Most: Improving the Patient Experience, to address gaps in and offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide and is acceptable for up to one (1) prescribed credit by the American Academy of Family Physicians.
Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices.
Did you know?
- Substantial evidence points to a positive association between the patient experience and health outcomes.
- Patients with chronic conditions, such as Diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.
- Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.
How will this benefit you and your office staff? You’ll learn tips and techniques to:
- Improve communication skills.
- Build patient trust and commitment.
- Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
The course can be accessed at www.patientexptraining.com using your smartphone, tablet, or computer.
Like you, Anthem is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.
Take the course today!
Effective October 14, 2018, Anthem BCBS will enforce the requirement to bill the correct modifier and HCPCS for services utilized. Incorrect billing will be rejected and claims will be returned to the provider for correction and resubmittal.
Durable Medical Equipment (DME) may be purchased, rented or rented until the purchase price has been paid.
Correct billing will allow member benefits to be applied correctly to include benefit accumulations for a member’s DME benefits. As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available on anthem.com. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To access the guidelines, select your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
The following new and revised medical policies were endorsed at the July 26, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > scroll down and select "Find Resources for Missouri", then from the Missouri Provider Home Page > select Medical Policies and Clinical UM Guidelines.
These medical policies were converted to clinical guidelines and became effective on September 20, 2018.
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New Clinical Guideline
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Content Moved From Clinical Guideline and/or Medical Policy
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CG-DME-45 Ultrasound Bone Growth Stimulation
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Content moved from DME.00027
No change to position statement → clinical indications
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CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
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Content moved from MED.00005
No change to position statement → clinical indications
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CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
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Content moved from MED.00051
No change to position statement → clinical indications
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CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
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Content moved from MED.00107
No change to position statement → clinical indications
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CG-MED-76 Magnetic Source Imaging and Magnetoencephalography
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Content moved from RAD.00019
No change to position statement → clinical indications
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CG-MED-77 SPECT/CT Fusion Imaging
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Content moved from RAD.00042
No change to position statement → clinical indications
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CG-REHAB-11 Cognitive Rehabilitation
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Content moved from MED.00081
Removed "Note" in Clinical Indications referring to
CG-REHAB-09 Acute Inpatient Rehabilitation
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CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
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Content moved from SURG.00014
No change to position statement → clinical indications
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CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
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Content moved from SURG.00020
No change to position statement → clinical indications
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CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
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Content moved from SURG.00049
No change to position statement → clinical indications
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CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
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Content moved from SURG.00074
Revised title - Previous title: Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring
No change to position statement → clinical indications
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CG-SURG-88 Mastectomy for Gynecomastia
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Content moved from SURG.00085
No change to position statement → clinical indications
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CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
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Content moved from SURG.00090
No change to position statement → clinical indications
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CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
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Content moved from TRANS.00018
No change to position statement → clinical indications
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These medical policies were converted to clinical guidelines and will become effective on October 31, 2018
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New Clinical Guideline
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Content Moved From Clinical Guideline and/or Medical Policy
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CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
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Content moved from SURG.00024
No change to position statement → clinical indications
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CG-SURG-85 Hip Resurfacing
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Content moved from SURG.00051
No change to position statement → clinical indications
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CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
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Content moved from SURG.00054
No change to position statement → clinical indications
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This new medical policy will be implemented on January 1, 2019
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New Medical Policy
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Content
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GENE.00049 Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
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MPTAC approved this new medical policy which reflects the following:
The use of a circulating tumor DNA (ctDNA) test for the diagnosis or treatment of cancer is considered investigational and not medically necessary (INV&NMN) for all indications
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This medical policy has been revised and will be effective January 1, 2019
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New Medical Policy
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Content
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ANC.00007 Cosmetic and Reconstructive Services: Skin Related
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MPTAC approved revision of policy which reflects the following:
• Added microneedling (also known as percutaneous collagen induction therapy or skin needling) as COS&NMN for all indications
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This medical policy is archived effective September 1, 2018
GENE.00008 - Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance In our ongoing efforts to encourage medical and behavioral health integration, Anthem continues to promote early identification and intervention of behavioral health issues through primary care.
Anthem currently reimburses for screening and assessment for behavioral health and substance use through billing the following codes:
- G0396 /99408 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes
- G0397 / 99409 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes
- G0442 - Annual alcohol misuse screening, 15 minutes £ G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
- G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
- G0444 - Annual depression screening, 15 minutes
Anthem also supports behavioral counseling for specific chronic conditions while in the primary care office. These services include:
- G0446 - Annual, face-to-face intensive behavioral therapy for cardiovascular disease, 15 minutes
- G0447 - Face-to-face behavioral counseling for obesity, 15 minutes
- G0473 - Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes
In addition, Anthem reimburses for the psychiatric collaborative care codes; procedure codes 99492, 99493, 99494 are used to report these services. These codes are reportable by primary care for their collaboration with a qualified behavioral health provider, such as a Psychiatrist, Licensed Clinical Social Worker, etc. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a BH specialist. The American Psychiatric Association (APA) has created a training program for primary care on the collaborative care model and the use of these codes. It can be found at APA Training Module.
The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for non-grandfathered policies. The appropriate use of modifier 33 will reduce claim adjustments related to preventive services and your corresponding refunds to members.
Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.
Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.
The CPT® 2018 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”
Beginning with dates of service on or after January 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) will require that facilities billing outpatient services on a UB04 report current and valid CPT or HCPCS codes with revenue codes as specified by the National Uniform Billing Committee (NUBC). Anthem will also require that outpatient facilities report current and valid CPT or HCPCS codes for remaining revenue codes when, and if, appropriate CPT or HCPCS codes are available for the revenue codes being reported. In addition, Anthem will require that applicable CPT or HCPCS modifiers be reported with the CPT or HCPCS codes to clarify or improve the accuracy of the procedure being reported when appropriate. For more information about this new policy, visit the Missouri facility reimbursement policy page at anthem.com/provider.
Beginning with dates of service on or after January 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) will include readmissions for psychiatric diagnoses as readmissions that are not be eligible for reimbursement when the readmission is within 30 days from discharge of the original admission for the same, similar or related diagnosis or for a complication arising out of the first admission. For more information, review the policy dated January 1, 2019 by visiting the Missouri facility reimbursement policy page at anthem.com/provider. Advanced imaging appropriate use criteria: Imaging of the heart
Effective for dates of service on and after January 28, 2019, the following updates will apply to the AIM Specialty Health© (AIM), a separate company, clinical appropriateness guidelines: advanced imaging appropriate use criteria: imaging of the heart:
Carotid duplex ultrasound
- Criteria removed for evaluation of syncope in patients with suspected extracranial arterial disease
- New criteria address evaluation of TAVR (TAVI) in patients with suspected or established extracranial arterial disease
Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, and coronary CT angiography (CCTA)
- Clarifications address exercise-induced syncope and exercise-induced dizziness, lightheadedness or near syncope in symptomatic patients with suspected coronary artery disease
MPI, stress echocardiography, cardiac PET
- Criteria added to allow annual surveillance of coronary artery disease in patients with established CAD post-cardiac transplant
- Clarified definition of established coronary artery disease when diagnosed by CCTA
- More restrictive for patients diagnosed with coronary artery disease by prior coronary angiography, as FFR must be ≤0.8
- More permissive for patients diagnosed with coronary artery disease by CCTA with FFR ≤0.8 (patients previously excluded)
Resting transthoracic echocardiography (TTE)
- New criteria for evaluation of ventricular function in patients who have undergone cardiac transplantation.
Cardiac MRI
- New criteria allows for annual study to quantify cardiac iron load in chronically ill patients with cardiomyopathy who require frequent blood transfusions (e.g., thalassemia)
- Removed allowance for annual LV function evaluation when echocardiography is suboptimal
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM 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 AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 1-800-554-0580, Monday-Friday, 8:30 a.m.-7:00 p.m. ET.
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 guidelines on AIM’s website.
Please note, this program does not apply to FEP. Effective for dates of service on and after January 28, 2019, the following updates will apply to the AIM Specialty Health© (AIM), a separate company, radiation oncology clinical appropriateness guidelines.
Breast cancer
- Removed age and tumor size criteria for accelerated whole breast irradiation (AWBI)
Rectal cancer
- Modified criteria no longer limits treatment with IMRT for rectal adenocarcinoma
Pancreatic cancer
- Added criteria for SBRT in treating locally advanced or recurrent disease without evidence of distant metastasis
Head and neck cancer
- Added criteria to allow IMRT for head and neck lymphomas
- Clarified no IMRT for stage I/II glottic cancer
Lung cancer
- Added DVH parameter for cardiac V50
Sarcoma
- Removed preoperative and joint sparing requirements for IMRT
Prostate cancer
- Added discussion on hypofractionation
- Added discussion on brachytherapy
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM 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 AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 1-800-554-0580, Monday-Friday, 8:30 a.m.-7:00 p.m. ET.
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 guidelines on AIM’s website. Please note, this program does not apply to FEP or National Accounts. Effective for dates of service on and after January 28, 2019, CPT code A7047 (oral interface used with respiratory suction pump) will be removed from the AIM Specialty Health© (AIM), a separate company, sleep disorder management clinical appropriateness guidelines and will no longer apply.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM 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 AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-800-554-0580, Monday-Friday, 8:30 a.m.-7:00 p.m. ET.
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 guidelines on AIM’s website.
Please note, this program does not apply to FEP.
Extension for Community Healthcare Outcomes (ECHO)
Opioid overdose rates continue to rise. With the support of MAT ECHO, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website.
Benefits of participating include:
- Addiction treatment training.
- Free continuing education credits.
- Opportunity to receive expert input on your (de-identified) patient cases.
- Access to a virtual learning community for treatment guidelines, tools and patient resources.
- Opportunity to ask questions and get a variety of support from specialists.
Quality Medication-Assisted Therapy (MAT)
To help ensure members have access to comprehensive evidence-based care, Anthem is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.
When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with buprenorphine or, in some plans, methadone maintenance treatment in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.
For more information
For more information about best practices for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.
You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.
Please be sure to check the Health Care Reform Updates and Notifications and Health Insurance Exchange sections at anthem.com for new updates on health care reform and Health Insurance Exchanges.
Sign up to receive immediate notification of new information.
Note that in addition to this newsletter and our website, we also use our email communication, Network eUpdates, to communicate new information.
If you are not yet signed up to receive Network eUpdates, we encourage you to enroll now so you’ll be sure to receive all information that we send about Exchanges. Sign up here. Providers can access real-time, patient-specific prescription drug benefit information at the point of care. It is part of the e-prescribing process, and is located within a provider’s electronic medical record (EMR) system.
This functionality helps providers determine prescription coverage quicker by sharing information about patient drug cost, formulary, and coverage alerts such as prior authorization to sending a prescription to the pharmacy. This information can help providers proactively identify barriers to medication compliance. For example, if a medication is too costly for the member, alternatives can be discussed prior to the patient leaving the provider’s office.
Providers can find the following patient-specific prescription benefit information with their EMR:
- Formulary status of selected medication
- Pricing of medication at a retail and mail order pharmacy
- Formulary alternatives
- Coverage alerts, including prior authorization and step therapy
Providers should contact their IT department or EMR system with questions regarding access to real-time prescription drug benefit functionality. Upgrades to EMR software may be required.
Effective for dates of service on and after January 1, 2019, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
The following clinical guidelines or medical policies will be effective January 1, 2019:
Effective for dates of service on and after January 1, 2019, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy clinically equivalent review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Anthem’s clinically equivalent prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
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, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit https://www11.anthem.com/pharmacyinformation/. The commercial and marketplace drug lists are posted to the website quarterly (the first of the month for January, April, July and October). To locate “Marketplace Select Formulary” and pharmacy information, go to Customer Support, select your state, Download Forms and choose “Select Drug List.” 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. AllianceRX Walgreens Prime is the specialty pharmacy program for the FEP. You can view the 2018 Specialty Drug List or call us at 888-346-3731 for more information. The AIM Genetic Testing program requires ordering providers to request medical necessity review of all genetic testing services for individual Medicare Advantage members. Requesting this prior authorization will help ensure that the lab receives timely and accurate payment for these services.
Please submit genetic testing prior authorization requests to AIM through one of the following ways:
- Access AIM ProviderPortalSM 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 AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 800-714-0040, Monday–Friday, 7 a.m.–7p.m. CT.
For further questions regarding prior authorization requirements, please contact the Provider Services number on the back of your patient’s ID card.
Effective January 1, 2019, Anthem will transition its Medicare back pain management and cardiology programs from OrthoNet LLC to AIM Specialty Health® (AIM), a specialty health benefits company. Anthem has an existing relationship with AIM in the administration of other medical management programs. Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.
The Centers for Medicare & Medicaid Services has increased its emphasis on the appropriate use of statins among Medicare Advantage beneficiaries diagnosed with diabetes and cardiovascular disease. Please evaluate whether your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.
The 2013 American College of Cardiology and the American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events. High-intensity statin therapy is recommended if the patient has an estimated 10-year ASCVD risk greater than or equal to 7.5 percent. For males 21-75 and females 40-75 years of age with clinical ASCVD, high-intensity statin therapy is recommended unless contraindicated. These guidelines recommend statin therapy in these scenarios regardless of what patient LDL values are. Please evaluate if your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.
Formulary agents are listed below:
Moderate-intensity statin therapy (formulary agents)
|
Drug (brand)
|
Dose
|
|
atorvastatin**
|
10 mg, 20 mg
|
|
rosuvastatin*
|
5 mg, 10 mg
|
|
simvastatin**
|
20 mg, 30 mg, 40 mg
|
|
pravastatin**
|
40 mg, 80 mg
|
|
lovastatin**
|
40 mg
|
High-intensity statin therapy (formulary agents)
|
Drug (brand)
|
Dose
|
|
atorvastatin**
|
40 mg, 80 mg
|
|
rosuvastatin*
|
20 mg, 40 mg
|
*Rosuvastatin (Crestor) is a preferred brand medication on the Medicare formulary.
**Available for a $0 co-pay for most plans in 2018
Per guidance established by the Comprehensive Addiction and Recovery Act of 2016, the Centers for Medicare & Medicaid Services has established provisions to develop a pharmacy and prescriber home program for opioid medications.
Beginning January 1, 2019, Anthem will work with beneficiaries and providers to help to reduce the risk of opioid dependency by streamlining access to opioid medications. If a beneficiary is exhibiting at-risk opioid medication utilization, the plan sponsor will work with the beneficiary and provider to select a pharmacy home and prescriber home for the beneficiary’s opioid medications.
At risk is defined by CMS as:
- Greater than 90 mg per day cumulative morphine milligram equivalent (MME)
- Greater than three (3) opioid prescribers and greater than three (3) opioid dispensing pharmacies, or
- Greater than five (5) opioid prescribers, regardless of the number of pharmacies
Please note:
- Cancer, LTC and Hospice are exempt
- Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.
- Plan sponsors will request agreement from the provider selected as the home.
- At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.
- Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.
- Beneficiaries retain the right to request a coverage determination and may choose to change their Home pharmacy or prescriber at any time.
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