 Provider News NevadaFebruary 1, 2021 February 2021 Anthem Provider News and Important Updates -- NevadaAnthem Blue Cross and Blue Shield (Anthem) will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
This is a reminder to ensure that you are referring Anthem members to participating labs. LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs. The relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories. Physicians may continue to refer to all par providers as they have in the past.
Not only does your Anthem agreement obligate you to refer to participating labs where available, but members will only receive their full benefits from participating providers. As a result, referring your patient and our member to a non-participating lab may expose them to a greater financial responsibility. As a reminder, Quest Diagnostics is a non-participating laboratory for all lines of business.
Unfortunately, there are certain non-participating labs that are offering to waive or cap co-payments, coinsurance or deductibles to our members in order to increase their overall revenue. These practices undermine member benefits and may encourage over-utilization of services.
These billing practices are also questionable in their legality. Such a practice may present violations under state or federal anti-kickback laws.
For a listing of Anthem participating laboratories, please check our online directory. Go to anthem.com. Choose Select Providers, and pick your state if you haven't done so already. Under the Provider Resources heading, select Find Care.
Note: When searching for laboratory, pathology, or radiology services, under the field “I am looking for a:” select Lab/Pathology/Radiology; and then under the field “Who specializes in:”, select Laboratories, Pathology, or Radiology as appropriate for your inquiry.
LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs:
LabCorp is capable of providing services that range from routine testing, such as basic blood counts and cholesterol tests, to highly complex diagnosing of genetic conditions, cancers, and other rare diseases. LabCorp has specialized laboratories which cover the following areas of testing:
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· Allergy Program
· Cancer Testing
· Cardiovascular Disease
· Companion Diagnostics
· Dermatology
· Diabetes
· DNA Testing
· Endocrine Disorders
· Esoteric Coagulation
· Gastroenterology
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· Genetic Testing
· Genetic Counseling
· Genomics
· HLA Lab for National Marrow Donor Program
· Hematopathology
· Infectious Disease
· Immunology
· Liver Disease
· Kidney Disease
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· Medical Drug Monitoring
· Molecular Diagnostics
· Newborn Screening
· Pain Management
· Pathology Expertise w/range of Subspecialties
· Pharmacogenomics
· Preimplantation Genetic Diagnosis
· Reproductive Health
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· Obstetrics
/Gynecology
· Oncology
· Toxicology
· Whole Exome Sequencing
· Virology
· Women’s Health
· Urology
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Note: This relationship with LabCorp does not affect network hospital-based lab service providers, or contracted pathologists.
Effective with dates of service on and after April 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem Blue Cross and Blue Shield (Anthem) 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.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.
For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacyinformation. The commercial drug list is posted to the web site quarterly (the first of the month for January, April, July and October).
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
CAHPS is an annual standardized survey conducted from January to May to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may get the survey. Providers directly impact the majority of questions used for scoring.
These questions are:
- When you needed care right way, how often did you get it?
- How often did you get an appointment for a check-up or routine care as soon as you needed it?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed it?
- How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
- How would you rate your primary care doctor?
- How would you rate the specialist you see most often?
To learn more about CAHPS and how you can improve the patient experience, review the CAHPS Overview training by visiting https://mediproviders.anthem.com/nv.
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Disease Manag ement/Population Health is designed to support providers in caring for patients with chronic health care needs. Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) provides members enrolled in the program with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications.
Who is eligible?
Disease Management/Population Health case managers provide support to members with:
- Asthma
- Bipolar disorder
- COPD
- Diabetes
- Congestive heart failure
- Coronary artery disease
- HIV/AIDS
- Hypertension
- Major depressive disorder -- adults
- Major depressive disorder -- children and adolescents
- Schizophrenia
- Substance use disorder
Our case managers use member-centric motivational interviewing to identify and address health risks, such as tobacco use and obesity, to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.
For more information on our program and how to refer an Anthem member for this program, please visit our website at https://mediproviders.anthem.com/nv.
Your input and partnership is valued. Once your patient is enrolled in the Disease Management/Population Health program, you will be notified by the case manager assigned.
We look forward to working with you.
Effective February 1, 2021, Anthem Blue Cross and Blue Shield Healthcare Solutions will require prior authorization (PA) for the below additional injectable drugs. Please refer to the Precertification Look Up Tool for authorization requirements. Noncompliance with the new requirements may result in denied claims.
PA requirements will be added to the following codes:
- A9543 Injection, Yttrium Y-90 ibritumomab tiuxetan (Zevalin)
- A9590 Injection, Iodine I-131, iobenguane, 1 mCi (Azedra)
- A9513 Injection, Lutetium Lu 177, dotatate, therapeutic, 1 millicurie (Lutathera)
- A9606 Injection, Radium ra-223 dichloride, therapeutic, per microcurie (Xofigo)
Please use one of the following methods to request PA:
Federal and state law, as well as state contract language, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions.
On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Healthcare Solutions. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC (AMH Health). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020 Anthem and Clinical Criteria Web Posting September and October 2020 AMH Health. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
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