 Provider News MissouriSeptember 2022 Anthem Provider News - MissouriRegister today for the Exploring the Intersection of Race and Disability forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on September 21, 2022.
Anthem is committed to making healthcare simpler and reducing health disparities. We believe that continuing the discussion we started at our June 2022 event to deepen the conversation about the disability experience for people of is critically important. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.
Wednesday, September 21, 2022
4 p.m. to 5:30 p.m. ET
Please register for this event by visiting this link.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
We are carefully monitoring the recent outbreak of monkeypox infections in the U.S. and are working to support our members and our network care providers with information to help you respond appropriately in the context of your patient population.
The best source of up-to-date information is at the Centers for Disease Control and Prevention which has a dedicated monkeypox page for healthcare professionals.
In addition to resources for care providers, the CDC has developed educational materials for the public, available for free download online.
Frequently asked questions (FAQs)
Who can become infected?
With this recent outbreak, monkeypox has spread through close, intimate contact with someone who has monkeypox. Many cases initially occurred in men who have sex with men. However, anyone can get monkeypox.
How dangerous is the disease?
Monkeypox virus belongs to poxvirus family and infection is rarely fatal. Patients whose immune system is compromised are most at risk for severe disease, along with children younger than 8 years old, pregnant and breastfeeding people, and people with a history of atopic dermatitis or other active skin conditions.
What are monkeypox symptoms?
Patients often have a characteristic rash (well-circumscribed, firm, or hard macules evolving to vesicles or pustules) on a single site on the body. Patients may also present with a fever and muscle aches. The rash may start in the genital and perianal areas. The lesions are painful when they initially emerge, but can become itchy as they heal, and then go away after two to four weeks. Symptoms can be similar or occur at the same time as sexually transmitted infections.
How does monkeypox spread?
Monkeypox does not spread easily between people without close contact. Person-to-person transmission is possible by skin-to-skin contact with body fluids or monkeypox sores, or respiratory droplets during prolonged face-to-face contact, and less likely through contaminated items such as bedding, clothing, or towels. Patients are contagious until the scabs heal and are replaced by new skin.
Is there a monkeypox vaccine?
Yes, although at the time of this writing, availability is limited. Smallpox and monkeypox vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox, and vaccination after a monkeypox exposure may help prevent the disease or make it less severe. You can access the CDC’s vaccination updates online.
How can monkeypox be treated?
There are no treatments specifically for monkeypox virus infections. However, antiviral drugs and vaccines developed to protect against smallpox may be used to prevent and treat monkeypox virus infections.
Do I need to report a case of suspected monkeypox?
Yes. Contact your state health department if you have a patient with monkeypox. They can help with testing and exposure precautions.
What are the behavioral health impacts of monkeypox?
Studies reporting psychiatric symptoms have indicated that the presence of anxiety, depression, or low mood is common among hospitalized patients with monkeypox infection. Care providers can help by listening with compassion, understanding underlying behavioral health concerns that may be heightened during isolation, and refer patients to the appropriate level of support following a monkeypox diagnosis.
The Health Resources & Services Administration (HRSA) Women’s Preventive Services Guidelines recommend women receive at least one preventive care visit per year.
While many members may receive a standalone preventive care visit, well-women visits may also include prepregnancy, prenatal, postpartum, and interpregnancy visits. For members receiving prepregnancy, prenatal, postpartum, and/or interpregnancy care that is billed using a global maternity code (for example, CPT® 59400, 59510, 59610, 59618) or antepartum/postpartum codes (for example, CPT 59425, 59426, 59430), it is appropriate to submit a claim for a wellness visit (for example, CPT 99385, 99386, 99387, 99395, 99396, 99397) when recommended preventive care has been rendered for a member who has not received a wellness visit in the last year. This will help ensure recognition that recommended preventive services have been provided for our members.
Please note, wellness evaluation and management (E/M) codes should not be billed on the same day as global maternity or antepartum/postpartum codes. Providers should continue to verify eligibility and benefits for all members prior to rendering services.
This article was published in the August 2022 issue of Provider News; however, we inadvertently omitted the effective date. We have added the effective date of September 1, 2022, to the original article and included it below.
According to the American Medical Association (AMA) Current Procedural Terminology® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after September 1, 2022, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M.
If you have questions on this program, contact your contract manager or Provider Experience representative.
We recently informed you in Provider News of the change of the current provider data management system with a new and significantly improved Strategic Provider System (SPS). One of the major features of SPS requires claims be submitted with complete and correct information so claims process timely and accurately.
We have been experiencing a high number of claim denials due to incomplete or inaccurate information on the claims. Submitting claims with complete and correct data is critical to help ensure we are able to process your claims efficiently and accurately. All data fields on claims are used when building your claim records to process them.
Please 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.
Questions?
If you have questions about this information, contact your local Anthem Blue Cross and Blue Shield network consultant.
As a reminder, when billing medical drug codes to Anthem Blue Cross and Blue Shield, include these three components:
- National Drug Code (NDC)
- Quantity
- Unit of measure
To prevent possible denial of the billed code, please ensure all three components are included on the claim.
Keeping your provider directory information current is key for members and your healthcare partners to engage with you seamlessly. Please review your information regularly and let us know if any of your information we show in our online directory has changed.
To update your information, use our online Provider Maintenance Form. Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
Effective July 1, 2022, Anthem recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Anthem contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims.
The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Anthem for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.
The following Anthem benefit plans are in scope for participation in HiH:
- Commercial
- Medicare Advantage (Individual and Group)
- Medicare Advantage Special Needs plans, including Dual-Eligible Special Needs (D-SNP)
The following Anthem plans are out of scope for participation in HiH:
Note:
- Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Anthem suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
- Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
- Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
- Facility shall not bill Anthem or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
- Notify Anthem immediately through the utilization management nurse assigned to the HiH case when:
- An applicable member is admitted to the HiH program
- A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
- As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Anthem Agreement and/or as outlined in the applicable Anthem provider manual.
We will continue to update billing guidance as these programs evolve.
In June, Anthem Blue Cross and Blue Shield (Anthem) added new functionality to the provider enrollment tool hosted on Availity* to further automate and improve your online enrollment experience.
Who can use this new tool?
Digital provider enrollment is currently only available for professional practitioners.
Note: Facilities and providers who submit rosters or have delegated agreements will continue to use the existing enrollment process in place.
What features does the tool provide?
- Apply to add new practitioners to an already contracted group
- Apply and request a contract to enroll a new group of practitioners
- Monitor submitted applications statuses real-time with a digital dashboard
How the online enrollment application works
The system pulls in all your professional and practice details from Council for Affordable Quality Healthcare (CAQH) ProView to populate the information Anthem needs to complete the enrollment process — including credentialing, claims, and directory administration. Please ensure your provider information on CAQH is updated and in complete or re-attested status.
The online enrollment application will guide you through the process, and a dashboard will display real-time application statuses. You’ll know where each provider is in the process without having to call or email for a status.
Accessing the provider enrollment application
Log onto availity.com and select Payer Spaces > Anthem > Applications > Provider Enrollment to begin the enrollment process.
Before you begin
If your organization is not currently registered for Availity, the person in your organization designated as the Availity administrator should go to availity.com and select Register.
For organizations already using Availity, your administrator(s) will automatically be granted access to the provider enrollment tool.
Staff using the provider enrollment tool need to be granted the user role Provider Enrollment by an administrator. To find yours, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.
Need assistance with registering for Availity?
Log onto availity.com/Contact-Us.
Three things to do when you do not find your claim in Claim Status
We appreciate the positive feedback you have shared about the new Claim Status Send Attachment feature. This enhancement to the attachment process enables you to submit an attachment directly to your claim at availity.com* by simply selecting the new Send Attachment button. We want to keep that positive momentum by answering your questions about those times when you are not able to find your claim in the Claim Status application using Availity Essentials. Here are a few suggestions:
- Double check your search information. Is the member information entered correctly? Many times, it is as simple as double checking the basic information needed to search for the claim.
- Do you have a claim number? If we have requested additional information to process your claim, the claim number will be included in the letter to you. Use this claim number to search for your claim.
- If you have located your claim, but the Send Attachment feature is not displayed, we have a solution for you:
- From the Claims & Payment tab, select Attachments – New. This will take you to your Attachments Dashboard.
- From the Attachments Dashboard, select Send Attachment.
- From the dropdown, select Medical Attachment.
- Complete the form and use the Add Attachment button to upload your files.
- Select Send Attachments, and your documents will be attached to your claim.
Claims attachment learning opportunities
In collaboration with Availity Essentials, we have made it easy for you to learn when it is convenient for you. Through this on-demand webinar, learn how to submit claim attachments through Claim Status. Go here to access the course. If live webinars fit into your schedule, use go here to sign up today.
The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on May 12, 2022.
To view Medical Policies and 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 Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program [FEP®]), please visit fepblue.org > Policies & Guidelines.
New policies
Below are the new medical policies and/or clinical guidelines that have been approved.
* Denotes prior authorization required.
|
Policy/guideline
|
Information
|
Effective date
|
|
*DME.00046
Intermittent Abdominal Pressure Ventilation Devices
|
Intermittent abdominal pressure ventilation devices are considered investigational and not medically necessary (INV & NMN) for all indications
Listed existing HCPCS code K1021 (code effective 10/1/2021) for exsufflation belt; considered INV & NMN
|
12/1/2022
|
|
DME.00047
Rehabilitative Devices with Remote Monitoring
|
The use of rehabilitative devices with remote monitoring or adjustment capabilities (for example, ROMTech PortableConnect® and ROMTech AccuAngle®) is considered INV & NMN for all indications
No specific code for this type of device, considered INV & NMN; listed E1399 NOC
|
12/1/2022
|
|
DME.00048
Virtual Reality Assisted Therapy Systems
|
Use of virtual reality systems (for example, EaseVRx, SootheVR, and RelieVR) for screening, diagnosis, or treatment of a health condition is considered INV & NMN for all indications
No specific code for this type of device, considered INV & NMN; listed E1399 NOC
|
12/1/2022
|
|
*GENE.00059
Hybrid Personalized Molecular Residual Disease Testing for Cancer
|
Oncologic hybrid personalized molecular residual disease (MRD) tests are considered INV & NMN for all indications
No specific code currently for this test, considered INV & NMN; listed 81479 NOC
|
12/1/2022
|
|
* LAB.00048
Pain Management Biomarker Analysis
|
The functional pain biomarker urine test panel is considered INV & NMN for chronic pain management and for all other indications
Listed existing CPT® PLA code 0117U specific to this test; considered INV & NMN
|
12/1/2022
|
|
MED.00139
Electrical Impedance Scanning for Cancer Detection
|
Electrical impedance scanning for cancer detection is considered INV & NMN for all indications
No specific code for this type of scanning, considered INV & NMN; listed 99199 NOC
|
12/1/2022
|
|
TRANS.00039
Portable Normothermic Organ Perfusion Systems
|
Outlines the MN and INV & NMN criteria for Portable Normothermic Organ Perfusion Systems
No specific transplant-related CPT codes for this technology; listed 32999 NOC lung and 47399 NOC liver having MN criteria, listed 33999 heart and 53899 kidney considered INV & NMN
|
12/1/2022
|
Updated policies
Below are the current clinical guidelines and/or medical policies we reviewed, and updates were approved.
* Denotes prior authorization required.
|
Policy/guideline
|
Information
|
Effective date
|
|
CG-MED-90
Chelation Therapy
|
Moved content of MED.00127 Chelation Therapy to new clinical UM guideline document with the same title
HCPCS codes J0470, J0600, J0895, J3520, M0300, S9355 for chelation therapy now addressed in this document; considered NMN if criteria not met
|
7/6/2022
|
|
*GENE.00023
Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma
Previously titled: Gene Expression Profiling of Melanomas
|
· Revised title
· Expanded Scope and Position Statement to include cutaneous squamous cell carcinoma
· Added existing CPT PLA code 0315U for GEP for squamous cell carcinoma; considered INV & NMN
|
12/1/2022
|
|
*SURG.00011
Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised INV & NMN statement to NMN for products with MN indications
Updated to consider NMN where indicated; added HCPCS codes Q4259, Q4260, Q4261 effective 7/1/2022 for products considered INV & NMN
|
7/1/2022
|
|
*SURG.00097
Scoliosis Surgery
|
Added MN criteria for vertebral body tethering
CPT Category III codes 0656T, 0657T, and associated ICD-10-PCS codes for tethering considered MN when criteria are met (were considered INV & NMN)
|
7/6/2022
|
|
*MED.00132
Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
|
Added CPT Category III codes 0717T, 0718T, effective 7/1/2022 for autologous ADRC therapy for rotator cuff tear; considered INV & NMN
|
7/1/2022
|
|
DME.00011
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
|
Added CPT Category III code 0720T effective 7/1/2022 for PENFS device (e.g., IB-Stim); considered INV & NMN
|
7/1/2022
|
|
*GENE.00053
Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
|
Added CPT PLA code 0323U effective 7/1/2022, for metagenomic NGS assay; considered INV & NMN
|
7/1/2022
|
|
LAB.00027
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
|
Added existing CPT code 83520, considered INV & NMN for food allergy diagnoses
|
7/6/2022
|
|
*CG-GENE-14
Gene Mutation Testing for Cancer Susceptibility and Management
|
For CPT PLA code 0229U (Colvera test) descriptor revision only effective 7/1/2022
|
7/1/2022
|
|
*CG-GENE-21
Cell-Free Fetal DNA-Based Prenatal Testing
|
Added CPT PLA code 0327U effective 7/1/2022, for Vasistera test; considered MN based on diagnosis
|
7/1/2022
|
|
*GENE.00049
Circulating Tumor DNA Panel Testing (Liquid Biopsy)
|
Added CPT PLA code 0326U effective 7/1/2022, for Guardant360 panel; considered INV & NMN
|
7/1/2022
|
|
*GENE.00052
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
|
Added CPT PLA code 0329U for Oncomap test having MN criteria, and CPT PLA code 0331U for genome mapping test considered INV & NMN; both codes effective 7/1/2022
|
7/1/2022
|
|
*GENE.00056
Gene Expression Profiling for Bladder Cancer
|
For CPT code 0016M (Decipher Bladder TURBT) descriptor revision only effective 7/1/2022
|
7/1/2022
|
|
LAB.00003
In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
|
Added CPT PLA codes 0324U, 0325U effective 7/1/2022, for ovarian tumor drug response panels, considered NMN
|
7/1/2022
|
|
LAB.00019
Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
|
For CPT PLA code 0166U (Liverfast test) descriptor revision only effective 7/1/2022
|
7/1/2022
|
Beginning with date of services on or after December 1, 2022, Modifier FT is only allowed for reimbursement on critical care codes 99291, 99292, 99468, 99469, 99471, 99472, 99475, and 99476.
Modifier FT was created by the Centers for Medicare and Medicaid Services (CMS) and is included in our Claims Impacting Adjudication list located in the Related Coding section of our Modifier Rules policy (professional).
Modifier FT is defined as an unrelated evaluation and management (E/M) visit during a postoperative period or on the same day as a procedure or another E/M visit. (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated).
For specific policy details, visit the Anthem Blue Cross and Blue Shield reimbursement policy page.
In the December 2021 edition of Provider News, Anthem Blue Cross and Blue Shield (Anthem) announced that an update to our reimbursement policy titled Assistant at Surgery – Professional, effective for dates of service on or after March 1, 2022.
The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
This policy follows the Centers for Medicare and Medicaid Services (CMS) guidelines for the codes designated as MPFS Assistant Surgery payment indicator ‘2’ always requiring an assistant surgeon. Codes identified with MPFS Assistant Surgery payment indicators ‘0’, ‘1’, and ‘9’ are not allowed for reimbursement.
For specific policy details, visit the Anthem reimbursement policy page.
In the December 2021 edition of Provider News, Anthem Blue Cross and Blue Shield (Anthem) announced that a new commercial reimbursement policy titled Modifier 66 Surgical Teams – Professional would be effective for dates of service on or after March 1, 2022.
The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
Under this reimbursement policy, Anthem allows the of procedures eligible for surgical teams when billed with modifier 66. Anthem follows the CMS MPFS Team Surgery payment indicators and will allow services requiring team surgery billed with CMS MPFS payment indicator ‘1’ (sometimes) and ‘2’ (always) and will deny services billed with the indicator ‘0’ (never) and ‘9’ (not applicable).
For specific policy details, visit the Anthem reimbursement policy page.
Effective October 1, 2022, Anthem Blue Cross and Blue Shield (Anthem) and AIM Specialty Health®* (AIM), a separate specialty benefits management company, will launch a new Back Pain Management Program for fully insured members, as further outlined below.
Who is AIM?
Anthem has an existing relationship with AIM in the administration of other programs. Anthem is excited to expand this relationship to include additional services. AIM works with leading insurers 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.
What is the Back Pain Management Program?
In pursuit of the commitment to improve healthcare quality and costs, we have created a new voluntary Back Pain Management Program to help educate and support members as they navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.
The program will be utilizing predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.
Our member engagement process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors.
- Risk stratification to ensure the appropriate level of support is provided.
- Targeted outreach to members through our digital engagement platform, email, and calls.
- Customized education and support of provider treatments based on member’s specific needs.
- Education and support of services such as behavioral health as appropriate.
Who is included in this new program?
All fully insured members currently participating in AIM and Anthem programs are included.
The following groups are excluded: Self-funded (ASO) groups, Medicare Advantage (MA), Medicaid, Medicare, Medicare supplement, MA Group Retiree Services (GRS), Federal Employee Program® (FEP).
The AIM Back Pain Program microsite helps you learn more and access helpful information and tools such as program information and FAQs.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Blue Cross and Blue Shield Service Benefit Plan, also known as the Federal Employee Program (FEP) is now requiring new information on claims that are required by OBRA93 law to be priced at the Medicare allowance.
Members that are over 64 years old and do not have Medicare Part B coverage fall under the OBRA93 law for Medicare pricing. In order for us to obtain the Medicare pricing, the CMS 1500 claim must have a rendering provider ID submitted on the claim.
Claims submitted without the rendering provider ID will deny for the following message on the remit and require the provider to resubmit with this required field.
Remit message:
339 NEED PROVIDER NAME & NPI IN ORDER TO DETERMINE MEDICARE FEE SCHEDULE
This claim submission requirement applies to Federal employee member claims only. A Federal member can be identified with an R followed by 8 digits (for example, Rxxxxxxxx).
If you have any questions, please contact FEP Customer Service 800-392-8043.
Effective with dates of service on and after October 1, 2022, and in accordance with the IngenioRx* Pharmacy and Therapeutics (P&T) process, Anthem Blue Cross and Blue Shield 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.
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.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
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.
Prior authorization updates
Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0217
|
Amvuttra™ (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere® (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0217
|
Amvuttra (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
AIM Specialty Health®* (AIM) created new contact center phone numbers for Medicare providers to call for prior authorization requests. The new phone numbers are listed below.
Note: The old number is not available for requests after August 15, 2022, so please use this new number to submit new prior authorization AIM requests.
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Market
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New number
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Indiana
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833-342-1252
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Kentucky
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833-404-1677
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Missouri
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833-775-1956
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Ohio
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833-419-2143
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Wisconsin
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833-775-1959
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As always, the best way to reach AIM is to use the ProviderPortalSM. It is:
- Self-service.
- Available 24/7.
- Customizable with physician information.
- Easy to use and allows real-time determinations.
The ProviderPortal is a fast and efficient way to start a case. It also allows your team to:
- Check order status and view order history.
- Print/save PDF of order summary.
- Use multiple staff members to enter/view the practice’s orders.
- Increase payment certainty.
- Reference desk training and tutorials, including clinical criteria and CPT® lists.
If not already registered, your first step is to register your practice in the ProviderPortalSM.
On December 1, 2022, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for the following code. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code:
L6715 — Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement
Not all PA requirements are listed here. Detailed PA requirements are available on the provider website or by accessing Availity*.
Providers may also call Provider Services for assistance with PA requirements by referencing the number on the back of the patient’s member ID card.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare Part B drugs
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J0172
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Aduhelm (aducanumab-avwa)
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The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Anthem Blue Cross and Blue Shield. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.
For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at anthem.com/medicareprovider.
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com*. Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are three options for submitting attachments:
1. Through the attachments dashboard inbox:
- From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
2. Through the 275 attachment:
- Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
3. Through the Availity.com application:
- From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim, and use the Send Attachments button.
If you submit your claim through the Availity application:
1. Simply submit your attachment with your claim. 2. If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim, and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
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