We understand that submitting authorizations by phone or fax is time consuming and inefficient. We have a digital application, Interactive Care Reviewer (ICR), that makes it easy to submit, review, and check authorization status all in one place, electronically.

 

We’d like to invite you to a webcast that covers how to:

• Access ICR
• Create an authorization request
• Inquire on a previously submitted authorization
• Update a case
• Copy a case
• View letters associated with a case
• Request and check the status of an authorization appeal

 

Join us for an ICR learning webcast:

Wednesday, October 12, 2022, at 11 a.m. Eastern time

Register here

 

Visit the ICR Target page to register and to access self-service learning by viewing recorded learning sessions. Download ICR user guides and other job aides from the ICR Target page too. You can also register from the Provider Learning Hub by clicking on the ICR live webinar learning icon.

 

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In August, Anthem Blue Cross and Blue Shield (Anthem) replaced the current provider data management system with a new and significantly improved Strategic Provider System (SPS). The SPS data website will increase website data accuracy, transparency, and timeliness to create an enhanced provider experience.

 

We have found that a number of professional providers are submitting claims without a billing national provider identifier (NPI) number. Submitting claims with complete and correct data is critical to help ensure we are able to process your claims efficiently and accurately. Please submit your full address including your line 2 address (suite #, unit, etc.) when applicable. All data fields are used on claims when building your claim record.

 

Review your billing practices carefully to ensure provider tax identification number (TIN), billing national provider identifier (NPI), taxonomy code, and servicing/rendering provider information (if applicable) are submitted in the appropriate fields. 

 

Below are some tips to filing a complete and correct professional claim.

 

If you are filing professional claims electronically (supported by electronic data interchange or EDI):

• Billing provider — Loop (section) 2010:
• When the billing provider is an organization healthcare provider, the organization’s national provider identification (NPI) number is reported in field NM109
• The taxpayer identification number (TIN) of the billing provider must be reported in the REF segment of this loop
• The billing provider may be an individual only when the healthcare provider performing the services is an independent, unincorporated entity.
• Billing provider address must hold a physical address and should not contain any of the following: Post Office Box, P.O. Box, PO Box, Lock Box, or Lock Bin
• Rendering provider — Loop 2310:
• This loop or section of the EDI file is required when the rendering provider’s NPI is different from that carried in Loop ID-2010AA-billing provider. If not required by the EDI implementation guide, do not send.
• The rendering provider is the person or company who rendered the care.

 

If you are filing a professional claim via mail/fax (not supported by EDI):

• Facility information:
• Box 32: Include the address of the servicing facility — the address where services were rendered.
• Box 32a: servicing facility’s NPI — service location NPI
• Billing provider:
• The billing provider’s complete name, address, and phone number must be in Box 33.
• NPI must be reported in box 33a (group’s organization or individual provider is an independent, unincorporated entity).
• The TIN of the billing provider must be reported in box 25.
• Rendering provider:
• For claims that require a rendering provider, please ensure you are reporting the rendering provider NPI in box 24J. 

 

Review your billing practices carefully to ensure proper TIN, billing NPI, and rendering provider information (if applicable) are submitted in the appropriate fields.

 

Questions? 

If you have questions about this information, contact your local Anthem network consultant.

 

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Beginning with dates of service on or after January 1, 2023, Anthem Blue Cross and Blue Shield will update the Related Coding section of the policy with the following:

 

• Added CPT code 43497 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent.

 

For specific policy details, visit the reimbursement policy page at anthem.com.

 

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Effective as of July 27, 2022, Anthem Blue Cross and Blue Shield combined the Three-Dimensional (3D) Radiology Services- Facility and Three-Dimensional (3D) Radiology Services - Professional policies into a single policy. The Three-Dimensional (3D) Radiology Services - Professional policy was updated to include the facility-specific language from the facility policy, and the title was changed to Three-Dimensional (3D) Radiology Services – Professional and Facility. As a result, the Three-Dimensional (3D) Radiology Services - Facility policy will be retired.

 

For specific policy details, visit the reimbursement policy page at anthem.com.

 

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Effective July 8, 2022, Federal Employee Program (FEP) for Anthem Blue Cross and Blue Shield (Anthem) began participating in a real-time provider chat option through Availity Essentials. The secure portal allows providers to seek real-time answers to questions about prior authorization, precertification requirements, status check, and more.

 

Currently, only Missouri and Georgia providers can access the chat capability for Federal members. Chat is available from 8 a.m. to 7 p.m. ET through the secure provider website found at availity.com. Select Payer Spaces, Anthem, and access the chat through Chat with Payer.

 

Chat is one example of how FEP is using digital technology to improve the health care experience with the goal of saving valuable time.

 

With the success of the real-time chat option for Federal members, Anthem is implementing additional states ranging in dates from October 2022 through the first quarter of 2023.

 

October 2022 – Colorado, Connecticut, and Ohio.

December 2022 – Indiana, Maine, Nevada, and Virginia.

February 2023 – Kentucky, New Hampshire, New York, and Wisconsin.

 

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This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).

 

Our pharmacy benefit management partner, IngenioRx,* will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.

 

This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.

 

If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:

• IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
• IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.

 

These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.

 

When e-prescribing orders to  the mail and specialty pharmacies:

• Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
• If searching by NPI (National Provider Identifier), the NPI will not change.

 

In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.

 

Keeping you well informed is essential and remains our top priority. We will continue to provide updates prior to January and throughout 2023.

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.

 

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Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_®* (AIM), a separate company.

 

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

 

Step therapy updates

 

Effective for dates of service on and after January 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. 

 

Please note that infliximab agents are subject to step therapy today, and this is to notify of the changes in the preferred and nonpreferred products. Inflectra will become non-preferred and Avsola will become preferred as of January 1, 2023.

 

Access our Clinical Criteria to view the complete information for these step therapy updates.

 

Clinical Criteria	Status	Drug	HCPCS or CPT® code(s)
ING-CC-0062	Preferred	Avsola	Q5121
ING-CC-0062	Preferred	Infliximab Unbranded	J1745
ING-CC-0062	Preferred	Remicade	J1745
ING-CC-0062	Nonpreferred	Inflectra	Q5103
ING-CC-0062	Nonpreferred	Renflexis	Q5104

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

 

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Visit the Drug Lists page 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 Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

 

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

 

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

 

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