Provider News MissouriSeptember 2024 Provider Newsletter Contents
MOBCBS-CRCM-065291-24 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners: Claim format and elements | CLIA number location options | Referring provider name and NPI number location options | Servicing laboratory physical location | CMS-1500 (formerly HCFA-1500) | Must be represented in field 23 | Submit the referring provider name and NPI number in fields 17 and 17b, respectively. | Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the servicing address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23. | HIPAA 5010 837 Professional | Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01 | Submit the referring provider name and NPI number in the 2310A loop, NM1 segment. | Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02. |
To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and/or applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. If you have questions, please contact your Provider Relationship Management representative. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-029658-23-CPN29126, MULTI-BCBS-CRCM-066936-24 Effective December 1, 2024, Anthem is enhancing its claim edits system to ensure claims billed with pharmaceutical drug procedure codes are reported with the appropriate FDA-approved indicators for on- and off-label use. These enhanced claim edits provide an opportunity for Anthem to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if not billed with FDA indicator for on/off label use. If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will need to submit only the portion(s) of the medical record that is relevant to the drug provided. If you have questions about this notification, contact your contract manager or provider relationship management account representative. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-063032-24-CPN62565 At a glance:Last month, we published information about the Consolidated Appropriations Act (CAA) data attestation process for Commercial providers here. This article provides additional information for Commercial and Medicare Advantage providers about updating your provider data with us.Care providers contracted with us must verify or update their demographic data every 90 days using the Provider Data Management (PDM) capability on Availity Essentials for efficient claims processing and timely reimbursement.Updating and attesting data are critical for maintaining accurate service directories for members. Non-compliance with these requirements may result in removal from the online provider directory.Availity Essentials not only allows for data attestation but also provides digital applications that enable users to monitor submitted demographic updates in real time, review the history of previously verified data, and manage multiple updates within one spreadsheet via the Upload Roster feature.
What are the requirements for the attestation of demographic data?We require our contracted care provider partners to attest to their demographic data every 90 days. Maintaining your provider data is critical as it results in improved connection to members seeking care, supports the accuracy of claims processing, and allows for timely reimbursement, while aligning to a bold purpose of improving the health of humanity. How do I update and attest to my data?We require the use of the PDM capability available on Availity Essentials to update your provider or facility data. There are two options within Availity Essentials PDM that are available at no cost to care providers: - Multi-payer platform, which includes Directory Verification and Core PDM: allows care providers to make required updates using Directory Verification and changes using Core PDM
- Roster upload: allows care providers to submit multiple updates within one spreadsheet via the Upload Roster feature (the Upload Roster feature is currently only available and shared with the health plan)
Both the Multi-payer Platform and Roster Upload feature satisfy your 90-day attestation requirement. To attest to your provider data: - Log in to Availity Essentials.
- Navigate to My Providers > Provider Data Management.
- Select the action menu next to the business whose information you want to verify.
- Select Verify Directory Listing.
- Review each set of data for accuracy.
- Once complete, select Submit Verified Profile.
Organizations with no changes since their last submission may see a Quick Verify button that allows for directory verification in one click. Individuals registered for their TIN within the Availity Manage My Organization application on Availity Essentials will receive periodic automated emails and notifications in the Notification Center on Availity reminding them when their attestation is due or overdue. How do I access Availity Essentials and the PDM application?To access the PDM application, log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Within PDM you also have the ability to: - Monitor submitted demographic updates in real time with a digital dashboard.
- Review the history of previously verified data.
Why is updating and attesting to my data important?Our members use Find Care to make informed decisions about their healthcare and find quality doctors and hospitals. Keeping your data up to date ensures members have access to you when they need it the most. Failure to complete the 90-day attestation requirement puts your organization at risk of being non-compliant with the health plan’s policies and procedures and may result in removal from the online provider directory. What if I’m not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and secure. There is no cost to register or to use any of the digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, make sure to register all TINs associated with your account. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY (282-4548). How do I get training on the Availity PDM tool?You can learn about the Availity PDC tool by attending one of our training opportunities here: - For more information on Availity PDM, check out the Quick Start Guide here using your Availity Essentials user ID and password.
- For more information about the Roster Upload process:
- See the Roster Submission Guide on Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using PDM.
- Find training specifically for the Standard Template and Rules of Engagement by listening to our recorded webinar here.
- Take an on-demand class hosted by Availity to learn about Provider Data Management here.
What if I’m a behavioral health care provider?If you are a behavioral health care provider and assigned to Carelon Behavioral Health, Inc., follow the Carelon Behavioral Health process for attestation. Council for Affordable Quality Healthcare (CAQH) care providers should attest, confirm, or update their data through the CAQH Provider Data Portal. Non-CAQH care providers and facilities should attest, confirm, or update their data directly through the Carelon Behavioral Health Provider Portal. Contact us Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate Payer Spaces tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat. We are committed to finding solutions that help our care provider partners offer quality services to our members. For additional support, visit the Contact Us section of our provider website for the appropriate contact. Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-065692-24-CPN65572 To advance our operations towards a more digitally efficient model, when a care provider registers for electronic remittance advice (ERA/835), we will cease issuing paper remittances 30 days after the effective registration date. Care providers will receive their remittance electronically through ERA with the option to print copies via Availity Essentials as needed in the Remit Inquiry application located in Payer Spaces. Some care providers, despite successful registration, continue to receive remittances in both electronic and paper formats. We are actively addressing this redundancy by discontinuing the issuance of printed remittances. As a result, care providers who have enrolled for ERA/835 but are still receiving paper remittances will begin noticing a decrease in these paper transactions starting in late August. If you have yet to register for ERA and wish to switch to electronic remittance reception, we recommend that you configure your ERA settings through Availity Essentials or by working with your existing clearinghouse vendor. In the interest of facilitating electronic transactions, care providers interested in receiving electronic payments are encouraged to visit the EnrollSafe Enrollment Hub (payeehub.org). This transition is part of our ongoing commitment to streamlining our procedures, enhancing customer experience, and promoting environmental sustainability. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-065360-24-CPN65174 Improvements in search capabilities in Availity Essentials now result in faster and more accurate results. To help save you more time upfront while receiving more detailed eligibility & benefits information, we’ve expanded the Current Procedural Terminology® (CPT) code search capabilities in Availity Essentials’ Eligibility and Benefit tool. These optimizations enable the use of up to eight specific CPT or Healthcare Common Procedure Coding System (HCPCS) codes per transaction for faster, more accurate, and personalized search results, which include: - Authorization requirement notifications — so you know up-front if an authorization is needed.
- Additional plan-level benefit limitations details.
- Cost-share information displayed by places of service and procedure codes.
Making these details available on the search results pages can help you save time and effort by giving you access to the right information you need when you need it. Additionally, it reduces the need to contact us, resulting in fewer calls and chats over time. Watch the recorded training to see how you can start saving time today. Learning sessions show step-by-step how you can use the CPT code search capabilities in Availity Essentials to help increase your productivity. We're dedicated to supporting your success through digital solutions that help reduce your administrative burden and streamline your interactions with us. If you have any questions, contact your provider relationship management representative. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-062285-24-CPN60904 In our previous communications to you, we talked to you about using the Authorizations and Referrals application on Availity Essentials to get digital notification about your authorization cases and we mentioned the Preference Center where you can select your preferred method of communication for authorization cases. We are excited to share that we will launch the solution in mid-May. Here we would like to give you a quick recap on how to get the digital notification for your authorization case status and related decision letters along with how to set your preference for mode of communication regarding authorization cases. Navigating Availity Essentials for auth case status and digital auth decision letters:- Through Auth/Referral Inquiry, you can retrieve cases submitted by your organization via both digital and non-digital methods. You can also use the Pin to Dashboard feature to keep these cases on the Auth/Referral Dashboard, saving you from repeating the search in the future.
- You can get the most recent status of cases submitted by your organization on Auth/Referral Dashboard and get the case details including decision letters via View Details in the Actions menu. For pinned cases, select the case card to get the latest status and case details.
Access the Preference Center and set your preferencesThe Preference Center is located within Payer Spaces on Availity Essentials. Select the payer tile that corresponds to your market after selecting Payer Spaces from the top menu bar. Once in Payer Spaces, select the Preference Center application tile. Then you can select your organization and then set preference option for Authorization and Referrals. Adjust the preference to fit your business needs (between Digital Access (Default) and Digital + Mail) for tax IDs and NPIs of your organization. Additionally, you can add more NPIs to your current registration and set the preferred communication mode for the new NPIs under the selected tax IDs. Manage preferences (Availity Administrators)Availity Administrators can learn more about managing preferences related to authorization decision letters in the Custom Learning Center, available in Payer Spaces on Availity Essentials. After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the payer tile that corresponds to your market. Once in Payer Spaces, select the Custom Learning Center application, then select the Resources section to view or download the Reference Guide on managing receipt of Authorization Decision letters. Through our shared health vision, we can affect real change. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-062610-24-CPN62607 Fifty-three million, or more than one in five Americans, are family caregivers. Caregiving in the U.S. 2020 reports that caregivers face health challenges of their own, with nearly a quarter of caregivers finding it hard to take care of their own health and saying that caregiving has made their own health worse. Now, we have made it easy for providers to help their patients who are family caregivers reduce their stress and improve their health. Help for Cancer Caregivers’ new healthcare provider landing page has an easy-to-download flyer that can be given to patients to encourage them to visit Help for Cancer Caregivers. This evidence-based, interactive website allows family caregivers to take a brief survey to create a personal self-care guide, access social services, and browse topics like dealing with feelings, keeping health, day-to-day needs, working together, and long-distance caregiving. Studies show that family caregivers suffer from poorer physical health than those who do not have additional caregiving responsibilities. Studies have found that: - Caregivers show higher levels of depression.
- Caregivers suffer from high levels of stress and frustration, which can lead to burnout.
- Stressful caregiving situations may lead to harmful behaviors, such as abusing drugs or alcohol.
- Caregivers have an increased risk of heart disease.
- Caregivers have lower levels of self-care.
- Chronic diseases of caregivers are often more difficult to manage.
- Caregivers have an increased risk of sickness and premature death.
Evidence has also shown that education and intervention reduce caregiver strain, uncertainty, and helplessness and that information helps normalize the caregiver experience and enhances a sense of control. Access the healthcare provider landing page today. This website includes language and accessibility tools to support non-English speakers and people with accessibility needs. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-064165-24-CPN64037 The following Medical Policies and Clinical UM Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin. 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. Below are the new medical policies and/or clinical guidelines that have been approved. * Denotes prior authorization required Policy/guideline | Information | Effective date | *MED.00148 Gene Therapy for Metachromatic Leukodystrophy | - Outlines the MN and NMN criteria for gene therapy for metachromatic leukodystrophy
- New technology No specific code for Lenmeldy, listed NOC codes C9399, J3490, J3590
| 12/1/2024 | *RAD.00069 Absolute Quantitation of Myocardial Blood Flow Measurement | - The use of absolute quantitation of myocardial blood flow testing is considered INV&NMN for all indications
- Existing CPT® codes 0742T and 78434 and new CPT codes 0899T, 0900T effective 07/01/2024 will be considered INV&NMN
| 12/1/2024 | *SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | - Revised ocular indications, including the addition of SurSight to MN and NMN section and added new MN criterion addressing non-healing or persistent corneal epithelial defects
- Removed VersaWrap from INV&NMN statement
- Removed Phasix Mesh from INV&NMN statement
- Added Phasix Mesh and Phasix ST Mesh to MN and NMN statements
- Revised coding section for ocular indications to considered MN when criteria are met; no specific code for Phasix, included in listed NOC codes; added new HCPCS codes Q4311-Q4333 effective 07/01/2024 considered INV&NMN and removed deleted codes Q4210, Q4277
| 12/1/2024 |
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 | *LAB.00019 Proprietary Algorithms for Liver Fibrosis | Added new CPT PLA code 0468U effective 07/01/2024 for the NASHnext test, considered INV&NMN | 7/1/2024 | *LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy | Added new CPT PLA code 0456U effective 07/01/2024 for PrismRA test considered INV&NMN, replacing NOC codes | 7/1/2024 | *LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease | Added new CPT PLA code 0459U effective 07/01/2024 for Elecsys® Total Tau CSF (tTau) and β-Amyloid (1-42) CSF II (Abeta 42) Ratio, considered INV&NMN | 7/1/2024 | *MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease | - Revised MN criteria related to heart blocks
- Revised formatting in Clinical Indications section
Added existing HCPCS codes J0688, J0689, J0744, J2184, J2281 and new codes J0687, J2183 effective 07/01/2024, for brand non-equivalent products considered INV&NMN for Lyme disease | 7/1/2024 | *MED.00140 Gene Therapy for Beta Thalassemia | Added HCPCS code J3393 effective 07/01/2024 for Zynteglo (replacing NOC codes for Zynteglo) | 7/1/2024 | *MED.00146 Gene Therapy for Sickle Cell Disease | Added HCPCS code J3394 effective 07/01/2024 for Lyfgenia (replacing NOC codes for Lyfgenia) | 7/1/2024 | *SURG.00052 Percutaneous Vertebral Disc Procedures Previously titled: Percutaneous Vertebral Disc and Vertebral Endplate Procedures | - Revised Title
- Removed MN and NMN criteria for intraosseous basivertebral nerve ablation (BVNA) from Position Statement (other criteria available)
Criteria for intraosseous basivertebral nerve ablation (BVNA) have been transitioned to Carelon Medical Benefits Management Musculoskeletal guidelines Removed CPT codes 64628, 64629 and associated ICD-10-PCS codes | 9/1/2024 | *TRANS.00039 Portable Normothermic Organ Perfusion Systems | Added new CPT Category III codes 0894T, 0895T, 0896T effective 07/01/2024 for liver perfusion systems MN when criteria are met, replacing NOC code | 7/1/2024 |
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-064737-24 Effective December 1, 2024 Effective December 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services 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(s): Code | Description | 0420U | Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma | 0422U | Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate Guardant360 Response™, Guardant Health, Inc, Guardant Health, Inc | 0423U | Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition Genomind® Pharmacogenetics Report – Full, Genomind®, Inc, Genomind®, Inc | 0428U | Oncology (breast), targeted hybrid-capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden Epic Sciences ctDNA Metastatic Breast Cancer Panel, Epic Sciences, Inc, Epic Sciences, Inc | 0430U | Gastroenterology, malabsorption evaluation of alpha-1-antitrypsin, calprotectin, pancreatic elastase and reducing substances, feces, quantitative Malabsorption Evaluation Panel, Mayo Clinic/Mayo Clinic Laboratories, Mayo Clinic/Mayo Clinic Laboratories | 0435U | Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on cytotoxicity percentage observed, minimum of 14 drugs or drug combinations ChemoID®, ChemoID® Lab, Cordgenics, LLC | 0790T | Revision (eg, augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed | 0810T | Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies | 0815T | Ultrasound-based radiofrequency echographic multi-spectrometry (REMS), bone-density study and fracture-risk assessment, 1 or more sites, hips, pelvis, or spine | 0823T | Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography | 0824T | Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography), when performed | 0825T | Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (eg, interrogation or programming), when performed | 0826T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional, leadless pacemaker system in single-cardiac chamber | 0861T | Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; both components (battery and transmitter) | 0862T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only | 0863T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; transmitter component only | 0864T | Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy | 22836 | Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 7 vertebral segments | 22837 | Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments | 22838 | Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed | 31242 | Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve | 31243 | Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve | 33276 | Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed | 33279 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only | 33281 | Repositioning of phrenic nerve stimulator transvenous lead(s) | 33287 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator | 33288 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) | 37242 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) [when specified as genicular artery embolization] | 81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years Enhanced Liver Fibrosis™ (ELF™) Test, Siemens Healthcare Diagnostics Inc/Siemens Healthcare Laboratory LLC | 93150 | Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming | 93151 | Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system | 93152 | Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography | 93153 | Interrogation without programming of implanted phrenic nerve stimulator system | E0746 | Electromyograph Biofeedback | L5615 | Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control | Q4279 | Vendaje ac, per square centimeter | Q4287 | Dermabind dl, per square centimeter | Q4288 | Dermabind ch, per square centimeter | Q4289 | Revoshield + amniotic barrier, per square centimeter | Q4290 | Membrane Wrap-Hydro TM, per sq cm | Q4291 | Lamellas xt, per square centimeter | Q4292 | Lamellas, per square centimeter | Q4293 | Acesso dl, per square centimeter | Q4294 | Amnio quad-core, per square centimeter | Q4295 | Amnio tri-core amniotic, per square centimeter | Q4296 | Rebound matrix, per square centimeter | Q4297 | Emerge matrix, per square centimeter | Q4298 | Amnicore pro, per square centimeter | Q4299 | Amnicore pro+, per square centimeter | Q4300 | Acesso tl, per square centimeter | Q4301 | Activate matrix, per square centimeter | Q4302 | Complete aca, per square centimeter | Q4303 | Complete aa, per square centimeter | Q4304 | Grafix plus, per square centimeter |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider. Choose the Select a State ribbon and then find on the Resources tab. Contracted providers can also access Availity.com. UM AROW A2024M1469 In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-057223-24-CPN56904 The Federal Employee Program® (FEP) offers a quality reimbursement program for providers. Coding for CPT® II category codes for A1c results, blood pressure readings, and the first prenatal visit are reimbursed at $10 per code. The program has been a success in improving HEDIS® scores and data collection. The FEP Quality Reimbursement Program for PPO providers was revised as noted below effective May 12, 2023. Revisions to CPT II category II code requirements for $10 reimbursement:- Only professional HCFA billing providers
- Only these six places of service codes are applicable:
- 2 — telehealth not home
- 10 — telehealth home
- 11 — office
- 12 — home
- 17 — walk-in clinic
- 20 — urgent care
- Only a specific diagnosis code that coordinates with the applicable CPT II code
Submitting the claimSubmit the CPT II code in field 24 of the HCFA 1500 with a charge of $10. Use the applicable CPT II code, place of service code, and diagnosis code according to the information below. Blood pressure — systolic and diastolic readingsReimbursable DX codes: I10, I11.9, I12.9, I13.10, I15, I15.1, I15.8, I15.9, I16.0, I16.1, I16.9 3074F | Most recent systolic blood pressure less than 130 mm Hg | 3075F | Most recent systolic blood pressure 130-139 mm Hg | 3077F | Most recent systolic blood pressure greater than or equal to 140 mm Hg | 3078F | Most recent diastolic blood pressure less than 80 mm Hg | 3079F | Most recent diastolic blood pressure 80-89 mm Hg | 3080F | Most recent diastolic blood pressure greater than or equal to 90 mm Hg |
Hemoglobin A1cReimbursable DX codes: E10.8, E10.9, E11.8, E11.9 3044F | Most recent hemoglobin A1c (HbA1c) level less than 7.0% | 3046F | Most recent hemoglobin A1c (HbA1c) level greater than 9.0% | 3051F | Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% | 3052F | Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%
|
First prenatal visitThe first prenatal visit date of service must be on the claim (field 24A HCFA 1500) with the appropriate code. Reimbursable DX codes: Maternity-related diagnosis code 0500F | Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit, and in a separate field, the date of the last menstrual period [LMP]) (Prenatal) | 0501F | Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the LMP (Note: If reporting 0501F prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit) (Prenatal) |
For additional information about the FEP Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-063827-24-SRS63786, MULTI-BCBS-CM-064143-24-SRS63773 Anthem is excited to announce the development of the Blue National Physician Performance Dataset. This initiative is a collaborative approach between Blue Cross Blue Shield Association, Blue Health Intelligence (BHI), and Motive Medical Intelligence (MMI) to develop a consistent national approach to evaluating physicians at the National Provider Identifier (NPI) level that incorporates measures of quality of care, appropriateness of care, and cost/efficiency of care. Effective January 1, 2025, Anthem may incorporate the Blue National Physician Performance Dataset in various ways, including but not limited to: - Providing special opportunities to participate in product offerings.
- When members contact Anthem with requests for referral options.
- Developing provider designations in provider directory (FindCare) tools.
- Enhancing existing tools in FindCare and Cost Finder, such as Personalized Match, that assist members with identifying or sorting providers.
For more information on how physicians are evaluated within each of the three categories (quality, appropriateness, and cost), you can view the Blue National Physician Performance Dataset Evaluation Method. If you have any questions about the Methodology or your score, contact your local provider relationship management representative In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-059174-24-CPN57527, MULTI-BCBS-CM-059175-24-CPN57527 ATTACHMENTS (available on web): Blue National Physician Performance Dataset Evaluation Method (pdf - 0.11mb) The specialty pharmacy updates for 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 Carelon Medical Benefits Management, Inc. 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. The inclusion of a 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 or after December 1, 2024, 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) | CC-0264* | Anktiva (nogapendekin alfa inbekicept-pmln) | C9399, J9999 | CC-0166* | Hercessi (trastuzumab-strf) | J3590 | CC-0263* | Imdelltra (tarlatamab-dlle) | C9399, J9999 |
* Oncology use is managed by Carelon Medical Benefits Management. Site of care updates Update: In the May 2024 edition of Provider News, we announced the site of care review requirements for the following drugs would be effective August 1, 2024. Please be advised that the following drugs were not implemented to have SOC requirements added. Access our Clinical Criteria to view the complete information for these site-of-care updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0042 | Bimzelx (bimekizumab-bkzx) | C9399, J3590 | CC-0256 | Rivfloza (nedosiran) | J3490 | CC-0257 | Wainua (eplontersen) | C9399, J3490 | CC-0254 | Zilbrysq (zilucoplan) | J3490 |
Step therapy updates Effective for dates of service on or after December 1, 2024, 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. Access our Clinical Criteria to view the complete information for these step therapy updates. Clinical Criteria | Status | Drug | HCPCS or CPT code(s) | CC-0166 | Non-Preferred | Hercessi (trastuzumab-strf) | J3590 |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-065565-24-CPN65398 Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about: - Copayment/coinsurance requirements and their applicable drug classes.
- Drug lists and changes.
- Prior authorization criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October. To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed. Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits. Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access. Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-063546-24 Want to reduce administrative burden and help your patients save on prescription costs? With real-time prescription benefit (RTPB), care providers can access patient-specific drug benefit information within the e-prescribing process. This functionality allows care providers to proactively identify barriers to cost and improve medication adherence. "Prescription pickup rates have increased 3.2% and saved patients on average $40 per prescription with using real-time prescription benefit.” — Surescripts.2 When using real-time prescription benefit during e-prescribing, care providers can see patient-specific benefit information including: - Formulary status of selected medication.
- Patient cost share of medication at a retail and mail order pharmacy.
- Up to five formulary drug alternatives.
- Coverage alerts, including prior authorization and step therapy.
Benefits you and your patients will experience when using RTPB:- Clearer, faster information
- Opportunity to lower cost barriers
- Decreased administrative burden
- Reduced time to therapy
- Enhanced patient experience
How real-time prescription benefit works:- Prescriber enters prescription information through e-prescribing.
- The e-prescribing system triggers a data call to the pharmacy benefit manager (PBM).
- The PBM receives the real-time prescription benefit request.
- The PBM delivers cost, formulary, and utilization information for the selected pharmacy back to the prescriber’s electronic health record (EHR).
- Prescriber and patient make a choice together.
Help your patients save money on their prescriptions with EHR access to patient-specific drug coverage and out of pocket costs. Find out if your EHR vendor provides real-time prescription benefits information. There’s no charge for the service; however, you will need the latest version of your EHR. References: - Kleinsinger F. The Unmet Challenge of Medication Nonadherence. Perm J. 2018;22:18-033. doi: 10.7812/TPP/18-033. PMID: 30005722; PMCID: PMC6045499.
- Giaquinto K. Prescription Pickup Rates 3.2 Percentage Points Higher with Surescripts Real-Time Prescription Benefit, Saving Patients an Average of $38 Per Prescription. Surescripts. September 2022.
- Rodriguez S. Surescripts real-time prescription benefit drove medication adherence. EHRIntelligence. https://ehrintelligence.com/news/surescripts-real-time-prescription-benefit-drove-medication-adherence?_hsmi=226935530&_hsenc=p2ANqtz--HlMXEGIqFp9czAfA3_Z5V1uCL8ujtrmfRv3mTJ3EhaA0VCsVpQQmK9ifNmgQw4ApI_6rb1_AvlNFyilc9FXXymEO4zpPLFQUikhqNsjxAAA_8INg. Published September 21, 2022. Accessed November 2, 2022.
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-065105-24 Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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. HCPCS or CPT® codes | Medicare Part B drugs | J1599 | Alyglo (immune globulin intravenous, human-stwk) |
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-064688-24-CPN64482 Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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. HCPCS or CPT® codes | Medicare Part B drugs | C9399, J9999 | Anktiva (nogapendekin alfa inbekicept-pmln) | J3590 | Hercessi (trastuzumab-strf) | C9399, J9999 | Imdelltra (tarlatamab-dlle) |
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-064678-24-CPN64481 To help make it as easy as possible to keep up with annual changes to HEDIS documentation, Anthem created a library of HEDIS content for you. You’ll find tip sheets with coding information and more for many HEDIS measures and other documentation to help ensure accurate claims coding, which helps ensure accurate reimbursement. Go to the Optimizing HEDIS & STARS category to view all the communications. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-064528-24-CPN64263 |