It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier! Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.

Self-testing: Measurable difference when correct coding is reflected

This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it.  Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.

Value set ID and subgroup	Code	Description
INR HOME MONITORING	CPT CODE 93792	Patient/caregiver training for initiation of home INR monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results.
INR HOME MONITORING	CPT CODE 93793	Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab INR test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.
INR HOME MONITORING	HCPCS CODE G0248	Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results.
INR HOME MONITORING	HCPCS CODE G0249	Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include four tests.
INR HOME MONITORING	HCPCS CODE G0250	Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include four tests.

 

INR clinical quality measure:

The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

Clinical Quality Measure	Required documentation	CPT, HCPCS, LOINC and                                           CPT Performance Codes	Provider Specialty
INR Monitoring for Individuals on Warfarin*	Adults 18 years of age and older who have had at least one 56- day interval of warfarin therapy and received at least one INR monitoring test during each 56-day interval with active warfarin therapy in the measurement year. Excludes patients who are monitoring INR at home during the treatment period	CPT 85610 - Prothrombin time LOINC 34714-6 INR blood by coagulation assay 6301-6 INR in platelet poor plasma by coagulation assay 38875-1 INR in platelet poor plasma or blood by coagulation assay 46418-0 INR in capillary blood by coagulation assay 52129-4 INR in platelet poor plasma by coagulation - post heparin adsorption Excludes: G0248 - demonstrate use home INR monitoring G0249 - provide test materials and equipment for home INR monitoring G0250 - physician INR test review interpretation and management	No provider type restrictions

 

1231-0721-PN-NV

 

In a recent study published by Pediatrics¹, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.

The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.

The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.

• When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
• When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
• Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

HEDIS® measure WCC looks at the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

• Body mass index (BMI) percentile (percentage, not value)
• Counseling for nutrition
• Counseling for physical activity

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

Code services correctly to measure success

These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:

Description	CPT®	ICD-10-CM	HCPCS
BMI percentile		Z68.51-Z68.54
Counseling for nutrition	97802, 97803, 97804	Z71.3	G0270, G0271, G0447, S9449, S9452, S9470
Counseling for physical activity		Z02.5, Z71.82	G0447, S9451
Codes to identify outpatient visits: CPT — 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483 HCPCS — G0402, G0438, G0439, G0463, T1015

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

American Academy of Pediatrics. American Academy of Pediatrics raises concern about children’s nutrition and physical activity during pandemic. Available at: http://services.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/. Accessed December 10, 2020

1 https://pediatrics.aappublications.org/content/147/5/e2021050123?cct=2287#F1

1232-0721-PN-NV

Many members have both primary and secondary insurance policies, and it’s important to know which policy is primary. We want to make it as easy as possible for you to find out so you can avoid claim denials for not filing the secondary claim within the timely filing guidelines.

Before the member arrives for their appointment, check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto Availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for their appointment. After providing services, submit the member’s claim as usual – you can use Availity for that, too, through the Claims & Payments app.

If we are the secondary payer, we will need the explanation of benefits (EOB) from the primary carrier along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claim system will deny the claim because we don’t have the EOB. This can cause a delay in receipt of your payment and can even cause you to miss the timely filing guideline.

We want you to have of the information you need to know the very best way to file your claims. For more information about filing claims, visit Anthem.com/provider/claims-submissions. For help using Availity, log onto Availity.com and select the Help & Training tab.

 

1234-0721-PN-NV

 

CMS average sales price (ASP) third quarter fee schedule with an effective date of July 1, 2021 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on August 1, 2021. To view the ASP fee schedule, please visit the CMS website at cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

 

1197-0721-PN-NV

Effective for dates of service on and after October 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will increase the reimbursement penalty for failure to comply with the utilization management (UM) program’s prior authorization requirements for services rendered to commercial plan members. Late prior authorizations, and late notices in the case of emergency admissions, are currently subject to a penalty and will be subject to the increase in the penalty. Failure to comply with Anthem’s prior authorization requirements, and late notice requirements in the case of emergency admissions, will result in a 100% reduction in reimbursement to the provider and facility. 

 

As a reminder, Anthem requires prior authorization prior to the delivery of certain elective services in both the inpatient and outpatient settings. For an emergency admission, prior authorization is not required; however, you must notify Anthem of the admission within the timeframe specified in the Provider Manual or as otherwise required by law. Failure to give timely notification for emergency admissions will also result in reimbursement penalties of 100% to providers and facilities.

 

Enforcement of the program requirement will lead to greater consistency in our processes. This notice updates Anthem’s UM program reimbursement penalties and the corresponding sections of the Provider Manual to reflect this change to the reimbursement penalty for non-compliance. As a reminder, providers and facilities may not balance bill the member for any such reduction in payment.

1200-0721-PN-NV

Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving Star ratings.

 

Program objectives:

• Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas including telehealth, pharmacy measures, chronic disease monitoring, cancer screenings, documentation and more.
• Apply the knowledge you gain from the webinars to improve your organization’s quality.

 

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

 

REGISTER HERE for our upcoming clinical quality webinars!

 

1230-0721-PN-NV

For more than a decade, Blue Precision, Anthem Blue Cross and Blue Shield’s physician transparency program, has recognized specialists for meeting or exceeding established quality and cost effectiveness measures. Thank you to all those physicians participating in our networks and for the care you provide to our members.

Anthem is announcing that we have made the decision to retire our Blue Precision program effective December 31, 2021. Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.

 

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare. 

 

1202-0721-PN-NV

 

As previously communicated in the Anthem Blue Cross and Blue Shield (Anthem) May 2021 edition of Provider News, the AIM Rehabilitative program will be enhanced. Effective August 1, 2021, AIM Specialty Health_® (AIM), a separate company, will expand the AIM rehabilitative program to perform medical necessity review of the requested site of service for physical, occupational and speech therapy procedures for Anthem fully insured members.

 

AIM will require prior authorization for all outpatient facility and office-based rehabilitative and habiliative services. Prior authorization is recommended for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and ensure the member is receiving care at the appropriate site of service early in the process. After the evaluation, ongoing services will be subject to site of care review and require prior authorization, including post service review which may result in a denial of coverage for not medically necessary for the site of care. Requests that are not medically necessary at a hospital site may be approved for coverage at a free standing or office-based setting. AIM will use the following Anthem clinical UM guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. The clinical criteria to be used for these reviews can be found on the anthem.com clinical UM guidelines page. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, or services with diagnosis of autism.

 

AIM will begin accepting prior authorization requests on July 19, 2021 for services provided on or after August 1, 2021.  Prior authorization requests may be submitted via the AIM ProviderPortal_SM or by calling 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.  Monday through Friday.

 

AIM rehabilitation educational information                                                                              

The AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists and CPT code lists. Anthem also invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_.  Go to the AIM Rehabilitation microsite to access helpful information and register for an upcoming webinar on July 8^th or 27^th at 3:00 p.m. ET. If you have previously registered for other services managed by AIM, there is no need to register again.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

1209-0721-PN-NV

 

Medicaid

Managing illness can be a daunting task for our members. It is not always easy to understand test results, how to obtain essential resources for treatment, or who to contact with questions and concerns.

 

Anthem Blue Cross and Blue Shield Healthcare Solutions is available to offer assistance in these difficult moments with our Complex Care Management program. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals there to support members, families, PCPs, and caregivers. The complex care management process uses the experience and expertise of the Care Coordination team to educate and empower our members by increasing self-management skills. The complex care management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare.

 

Members or caregivers can refer themselves or family members by calling the Customer Service number located on their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

 

You can contact us by phone at 844-396-2330. Case Management business hours are Monday to Friday from 8 a.m. to 5p.m. Pacific time.

 

ANV-NU-0229-21

This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).

 

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for Anthem integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

 

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

 

ANV-NU-0213-21

 

Medicare Advantage

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

• Prior authorization requirement changes effective September 1, 2021 – UM AROW 1845

 

ABSCRNU-0227-21

Medicaid

(Effective 10/01/21)

 

Anthem Blue Cross and Blue Shield Healthcare Solutions does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at mediproviders.anthem.com/nv.

 

ANV-NU-0203-21

 

This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).

 

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for Anthem integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

 

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

 

ANV-NU-0213-21

Mental disorders among children may cause serious changes in the way children typically learn, behave or handle their emotions, which cause distress and problems getting through the day. Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5),¹ to help diagnose mental health disorders in children.

 

The most common mental disorders of childhood and adolescence fall into the following categories:

• Anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobic disorder)
• Depression
• Posttraumatic stress disorder (PTSD)
• Separation anxiety disorder
• Social anxiety disorder
• Obsessive-compulsive disorder
• Bipolar disorder
• Disruptive behavioral disorders (attention-deficit/hyperactivity disorder [ADHD], conduct disorder, and oppositional defiant disorder)
• Eating disorders
• Schizophrenia (less common).

 

Other conditions and concerns that affect children’s learning, behavior and emotions include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

 

ICD-10-CM coding:

• Chapter 5 of the ICD-10-CM code set categorizes mental disorders.
• Codes from chapter 5 are assigned based on the express documentation of the provider’s clinical judgment regarding the patient’s mental or behavioral disorder(s). The codes are not assigned based on symptoms, signs, or abnormal clinical laboratory findings.

 

Affective disorders

 

Major depressive disorder (MDD) is classified in ICD-10-CM as:

• F32: Major depressive disorder, single episode
• F33: Major depressive disorder, recurrent

 

When documenting major depressive disorder, keep in mind that proper and specific coding requires clear documentation of the:

• Episode: single versus recurrent.
• Severity: mild, moderate, or severe.
• Psychotic features, when present.
• Status of remission as either partial or full.

Remember to document any established causality between multiple mental health conditions. For example:

• Suppose the patient has a diagnosis of depression and a diagnosis of anxiety with a causal relationship between the two conditions. In such cases, documentation must establish the relationship by stating depression with, due to, or related to anxiety

 

ICD-10-CM classifies bipolar disorders under the following categories:

• F30: Manic episode (bipolar disorder, single manic episode, and mixed affective episode)
• F31: Bipolar disorder (manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)
• F34: Persistent mood affective disorders (cyclothymic disorder and dysthymic disorder)
• F39: Unspecified mood affective disorder (affective psychosis not otherwise specified).

 

Nonpsychotic mental disorders

Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders are classified in categories F40 to F48.

 

Anxiety disorders are classified in ICD-10-CM under the following categories:

• F40: Phobic anxiety disorders
• F41: Other anxiety disorders
• F42: Obsessive-compulsive disorder.

 

Reactions to stress

ICD-10-CM provides category F43 for coding reactions to severe stress and adjustment disorders. Code F43.0, Acute stress reaction, classifies acute reaction to stress, including acute crisis reaction, crisis state, and psychic shock.

 

Posttraumatic stress disorder (PTSD) is classified in ICD-10-CM to subcategory F43.1, with
fifth-characters for unspecified, acute, or chronic.

 

Adjustment disorders are classified to subcategory F43.2, with the fifth-character axis being the nature of the reaction, such as anxiety, depression, or other symptoms. For example:

• 24: Child adopted from a foreign country, suffering from culture shock with conduct disturbance.

 

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 to F59 are devoted to behavioral syndromes associated with physiological disturbances and physical factors. These codes are not assigned when the conditions are present due to mental disorders classified elsewhere or organic in origin. This grouping includes, for example:

• : Eating disorders (such as anorexia nervosa and bulimia nervosa)
• : Sleep disorders, not due to a substance or known physiological condition
• F54*: Psychological and behavioral factors associated with disorders or diseases classified elsewhere

F59: Unspecified behavioral syndromes associated with physiological disturbances and physical factors

* Code F54 classifies psychological and behavioral factors associated with diseases classified elsewhere. Typical conditions that are often associated with code F54 include asthma and dermatitis.

 

Schizophrenic disorders:

• Those types of disorders are classified in category F20, with a fourth character indicating the type of schizophrenia.
• The codes from category F20 are followed by an excludes one note indicating they should not be reported with codes classifying a brief psychotic disorder (F23) , cyclic schizophrenia (F25.0), schizoaffective disorder (F25-F25.9) and schizophrenic reaction not otherwise specified (NOS) (F23).
• Assign code F20.9, Schizophrenia, unspecified, for chronic schizophrenia with acute exacerbation. The existing ICD-10-CM codes for schizophrenia do not differentiate severity or an acute exacerbation (AHA Coding Clinic, Second Quarter 2019, p.32).

 

Attention deficit hyperactivity disorder (ADHD)

ICD-10-CM codes for ADHD include:

• 0: Attention-deficit hyperactivity disorder, predominantly inattentive type.
• 1: Attention-deficit hyperactivity disorder, predominantly hyperactive type.
• 2: Attention-deficit hyperactivity disorder, combined type.
• 8: Attention-deficit hyperactivity disorder, other types.
• 9: Attention-deficit hyperactivity disorder, unspecified type.

 

The ADHD diagnosis may not be established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out.

ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as rule out, working diagnosis or other similar terms indicating uncertainty.

 

Instead, the outpatient coding guidelines instruct to code the condition(s) to the highest degree of certainty for that encounter/visit, requiring the use of codes that describe symptoms, signs or another reason for the visit.

 

History codes (categories Z80 to Z87) may be used as secondary codes if the historical condition or family history impacts current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:

• 59: Personal history of other mental and behavioral disorders.
• 8: Family history of other mental and behavioral disorders.

 

Psychosocial circumstances

ICD-10-CM provides codes for behaviors that are not classified as behavioral disorders, such as:

• 840: Attention and concentration deficit
• 83: Excessive crying of child, adolescent, or adult
• 87: Impulsiveness
• 81: Obsessive-compulsive behavior.

 

Resources:

1 American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5)

• ICD-10-CM Expert, 2021. Optum
• Coding Clinic. Optum
• Mental illness in children.
  com/anxiety-panic/mental-health-illness-in-children
• Children’s Mental Health gov/childrensmentalhealth/symptoms.html

 

ANV-NU-0216-21

Medicaid

Well-child visits and vaccinations are essential services

In May 2020, the CDC released a report showing a drop in routine childhood vaccinations as a result of COVID-19; a result of stay-at-home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.

To encourage well-visits and vaccinations, here are some extra steps you can take to ensure visits are as safe as possible for both patients and staff. They include:

• Scheduling sick visits and well-child visits during different times of the day.
• Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms.
• Offering sick visits and well-child visits in different locations.

 

It is important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.

 

Help your patients earn rewards

For additional encouragement, Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) members can earn $25 or more in gift cards for completing vaccines and/or well visits through our Healthy Rewards program. Please encourage your patients to enroll in the program on the Anthem website so they can earn rewards for these activities.

See chart below:

Anthem	Childhood Immunization Status Combo 10 (CIS-10)	Child and Adolescent Well Care Visits (WCV)
Ages	0 to 1 (before 2nd birthday)	15 months to 19 years
Reward amount	$25	$25

 

 Patients can enroll online at mss.anthem.com/nv or by calling 1-888-990-8681 (TTY).

 

Helpful information for keeping babies and children healthy:

Childhood Immunization Status (CIS) Combination 10 HEDIS^® measure requires that all children are immunized by their 2^nd birthday:

• Four DTap (diphtheria, tetanus and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, rubella)
• Three HiB (H influenza type B)
• Three Hep B (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One Hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two influenza (flu)

 

Billing codes:

• MMR:
  • CPT^®: 90707, 90710
  • ICD-10-CM: B05.0-4, B05,81, B05.89, B05.9
• Mumps:
  • ICD-10-CM:0-3, B26.81-85, B26.89, B26.9
• Rubella:
  • ICD-10-CM:-00-02, B06.09, B06.81-82, B06.89, B06.9
  • CPT: 90706
• Rubella antibody:
  • CPT: 86762
• Hepatitis A:
  • CPT: 90633
  • ICD-10-CM:0, B15.9
• Influenza:
  • CPT: 90655, 90657, 90662, 90673, 90685, 90686-90689
  • HCPCS: G0008
• Rotavirus vaccine (RV):
  • CPT: 90681 (two-dose), 90680 (three-dose)

 

Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) Combination 2 HEDIS measure:

• One meningococcal vaccine (MCV) injection between 11 and 13 years of age
• One tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between 10 and 13 years of age
• Two or three HPV vaccines between 9 and 13 years of age

 

Billing codes:

• Meningococcal:
  • CPT: 90734
• Tdap:
  • CPT: 90715
• HVP:
  • CPT: 90649, 90650, 90651

 

Please refer to the Anthem HEDIS coding booklet for coding guidelines.

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

ANV-NU-0219-21

Medicaid

What Matters Most: Improving the Patient Experience is an online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

 

The What Matters Most training can be accessed at patientexptraining.com.

 

ANV-NU-0220-21

Medicaid

As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address patients’ needs. Anthem Blue Cross and Blue Shield Healthcare Solutions

(Anthem) wants to help.

Cultural competency resources

Here is an overview of the cultural competency resources available on our provider website.

• Cultural Competency and Patient Engagement includes:
• The impact of culture and cultural competency on healthcare.
• A cultural competency continuum, which can help providers assess their level of cultural competency.
• Disability competency and information on the Americans with Disabilities Act (ADA).
• Caring for Diverse Populations Toolkit includes:
• Comprehensive information, tools and resources to support enhanced care for diverse patients and mitigate barriers.
• Materials that can be printed and made available for patients in provider offices.
  • Regulations and standards for cultural and linguistic services.
• My Diverse Patients offers:
• A comprehensive repository of resources to providers to help support the needs of diverse patients and address disparities.
• Courses with free continuing education credit through the American Academy of Family Physicians.
  • Free accessibility from any device (for example, desktop computer, laptop, phone or tablet), no account or login required.

 

To access these resources, go to providers.anthem.com/nv > Manuals, Directories, Training & More > Tutorials, Reference Guides and Other Resources.

 

In addition, providers can access Stronger Together, which offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

 

ANV-NU-0224-21

Medicaid

In a recent notification, we shared that effective May 1, 2021, the following codes would be included in our prior authorization review process. Please be advised that these codes will not be included in our prior authorization process at this time.

Clinical Criteria	HCPCS or CPT® code(s)	Drug
ING-CC-0182	J1756	Venofer
ING-CC-0182	J2916	Ferrlecit
ING-CC-0182	J1750	Infed
ING-CC-0182	J1439	Injectafer
ING-CC-0182	Q0138	Feraheme
ING-CC-0182	J1437	Monoferric

 

 

ANV-NU-0226-21

Medicare Advantage

 

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit clinical criteria to search for specific policies. If you have questions or would like additional information, use this email.

 

Please see the explanation/definition for each category of clinical criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Note: The clinical criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

 

Effective date	Document number	clinical criteria title	New or revised
July 16, 2021	ING-CC-0195*	Abecma (idecabtagene vicleucel)	New
July 16, 2021	ING-CC-0191*	Pepaxto (melphalan flufenamide; melflufen)	New
July 16, 2021	ING-CC-0192*	Cosela (trilaciclib)	New
July 16, 2021	ING-CC-0193*	Evkeeza (evinacumab)	New
July 16, 2021	ING-CC-0194*	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	New
July 16, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
July 16, 2021	ING-CC-0064	Interleukin-1 Inhibitors	Revised
July 16, 2021	ING-CC-0159*	Scenesse (afamelanotide)	Revised
July 16, 2021	ING-CC-0151	Yescarta (axicabtagene ciloleucel)	Revised
July 16, 2021	ING-CC-0145*	Libtayo (cemiplimab-rwlc)	Revised
July 16, 2021	ING-CC-0130*	Imfinzi (durvalumab)	Revised
July 16, 2021	ING-CC-0127	Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)	Revised
July 16, 2021	ING-CC-0075*	Rituximab Agents for Non-Oncologic Indications	Revised

 

 

ABSCRNU-0233-21

 

Medicaid

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at mediproviders.anthem.com/nv/pages/medical-policies.aspx. 

 

You can request a free copy of our UM criteria from Provider Services at 844-396-2330. Providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the number listed below. To access UM criteria online, go to mediproviders.anthem.com/nv/pages/medical-policies.aspx.

 

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Fax:
  • DME, physical therapy/occupational therapy/speech therapy, pain management, home care, home infusion requiring nursing services, insulin pumps, hyperbaric treatment, or wound care: 866-920-8362
  • Inpatient services: 844-442-8009
  • Outpatient services: 844-430-6807
  • Pharmacy prior authorization, including home infusion injectables, continuous glucose monitoring equipment, and diabetic supplies: 844-490-4876
• Phone: 844-396-2330
• Pharmacy: 844-396-2330
• Availity* Portal: availity.com

 

Have questions about utilization decisions or the UM process?

Call our Clinical team at 844-396-2330 Monday through Friday from 8 a.m. to 5 p.m. Pacific time.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions.

ANV-NU-0230-21

 

Medicaid

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit anthem.com/search.html.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *CG-LAB-17 - molecular gastrointestinal pathogen panel (GIPP) testing for infectious diarrhea in the outpatient setting
  • Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
• *GENE.00056 - gene expression profiling for bladder cancer
  • Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered investigational and not medically necessary
• *LAB.00038 - cell-free DNA testing to aid in the monitoring of kidney Transplants for rejection
  • Cell-free DNA testing is considered investigational and not medically necessary as a non-invasive method of determining the risk of rejection in kidney transplant recipients
• *LAB.00039 - pooled antibiotic sensitivity testing
  • Pooled antibiotic sensitivity testing is considered investigational and not medically necessary in the outpatient setting for all indications
• *SURG.00159 - focal laser ablation for the treatment of prostate cancer
  • Focal laser ablation is considered investigational and not medically necessary for the treatment of prostate cancer
• *TRANS.00037 - uterine transplantation
  • Uterine transplantation is considered investigational and not medically necessary for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus
• *ANC.00008 - cosmetic and reconstructive services of the head and neck
  • Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary
• *CG-OR-PR-04 - cranial remodeling bands and helmets (cranial orthotics)
  • Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
• *CG-SURG-78 - locoregional and surgical techniques for treating primary and metastatic liver malignancies
  • Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor [GM-CSF]) as not medically necessary for all liver-related indications
• *CG-SURG-82 - bone-anchored and bone conduction hearing aids
  • Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
  • Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
  • Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications
• CG-GENE-22 - gene expression profiling for managing breast cancer treatment
  • A new clinical guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
• CG-GENE-23 - genetic testing for heritable cardiac conditions
  • A new clinical guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
• CG-SURG-110 - lung volume reduction surgery
  • A new clinical guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021

 

AIM Specialty Health_®* clinical appropriateness guideline updates.

To view AIM guidelines, visit the AIM Specialty Health page.

• The Small Joint Surgery Guideline has been revised and will be effective on March 14, 2021.
• The following Guidelines have been revised and will be effective on July 1, 2021:
• * Joint Surgery
• * Spine Surgery

 

Medical policies

On February 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions

(Anthem). These guidelines take effect on July 1, 2021.

Publish date	Medical policy number	Medical policy title	New or revised
4/1/2021	*GENE.00056	Gene Expression Profiling for Bladder Cancer	New
4/7/2021	*LAB.00038	Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection	New
4/7/2021	*LAB.00039	Pooled Antibiotic Sensitivity Testing	New
4/7/2021	*SURG.00159	Focal Laser Ablation for the Treatment of Prostate Cancer	New
4/7/2021	*TRANS.00037	Uterine Transplantation	New
4/7/2021	*ANC.00008	Cosmetic and Reconstructive Services of the Head and Neck	Revised
4/7/2021	MED.00087	Optical Detection for Screening and Identification of Cervical Cancer	Revised
2/18/2021	SURG.00121	Transcatheter Heart Valve Procedures	Revised
2/18/2021	SURG.00145	Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)	Revised

 

Clinical UM guidelines

On February 11, 2021, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on February 25, 2021. These guidelines take effect on July 1, 2021.

Publish date	Clinical UM guideline number	Clinical UM guideline title	New or revised
4/7/2021	*CG-LAB-17	Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting	New
2/18/2021	CG-GENE-21	Cell-Free Fetal DNA-Based Prenatal Testing	Revised
4/7/2021	CG-MED-26	Neonatal Levels of Care	Revised
2/18/2021	CG-MED-87	Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications	Revised
4/7/2021	*CG-OR-PR-04	Cranial Remodeling Bands and Helmets (Cranial Orthotics)	Revised
2/18/2021	CG-SURG-55	Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation	Revised
4/7/2021	CG-SURG-71	Reduction Mammaplasty	Revised
4/7/2021	*CG-SURG-78	Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies	Revised
4/7/2021	*CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids	Revised
4/7/2021	CG-SURG-97	Cardioverter Defibrillators	Revised

 

 

ANV-NU-0231-21

Medicaid

The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment participating practitioners and members in our system, Anthem Blue Cross and Blue Shield Healthcare Solutions has adopted a Members’ Rights and Responsibilities Statement, which is located in the provider manual.

 

If you need a physical copy of the statement, call Provider Services at 844-396-2330.

 

ANV-NU-0233-21

Medicaid

Doluce David Ezeanolue, MD


David Ezeanolue, MD (Dr. Ez) is an experienced, multiple board-certified specialist who has practiced in Las Vegas since 1997. He graduated at the top of his medical school class and is widely respected as an excellent physician by his patients. He is an internationally recognized interventional pain specialist as well as a top 2 percentile board-certified internist (American Board of Internal Medicine). He has received numerous America’s Top Physician Awards from Consumer Research Council of America.

He is a Fellow of Interventional Pain Management (World Institute of Pain). He is also certified by the American Boards of Interventional Pain Practice, Internal Medicine, Electrodiagnostic Medicine, Addiction Medicine, Physical Medicine and Rehabilitation. Dr. Ez is also certified by the American Board of Certified Independent Medical Examiners.

 

Dr. Ez brings a wealth of experience to Apex Medical Center as he has amassed many impressive skills that he uses to treat patients from in and around Las Vegas and Henderson, Nevada. At Apex Medical Center, Dr. Ez is honored to put these skills and experience to use helping patients achieve their personal best in health and wellness. Working to find effective solutions for a wide range of physical ailments is also a driving force in his medical practice. His expertise, along with his personable nature, has earned Dr. Ez many loyal patients who turn to him in times of need.

 

Each quarter, we will feature one of our amazing providers. This feature is meant to highlight the diversity in our network and the membership we serve. We can also highlight shared best practices. If you would like to be considered, please email your Provider Experience consultant. You only need to write in once. We will revisit submissions each quarter. Thank you for all the work you do.

 

ANV-NU-0235-21

Medicaid

Effective September 1, 2021, prior authorization (PA) requirements will change for 0205U, 0209U, and 0218U. The medical codes listed below will require PA from Anthem Blue Cross and Blue Shield Healthcare Solutions for Nevada Medicaid members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.

Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• 0205U — ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negative for neovascular age-related macular-degeneration risk associated with zinc supplements
• 0209U — cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities
• 0218U — neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants

 

To request PA, you may use one of the following methods:

• Web: anthem.com/nv
• Fax: 800-964-3627
• Phone: 844-396-2330

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool through the Availity* Portal at availity.com or by going to the provider website at providers.anthem.com/nv > Login. Contracted and noncontracted providers unable to access Availity can call Provider Services at 844-396-2330 for assistance with PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions.

ANV-NU-0236-21

Medicaid

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

 

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases.
• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

 

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.ANV-NU-0238-21

Medicaid

Effective September 1, 2021, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield Healthcare Solutions for Nevada Medicaid members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.

Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• 0153U — oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement
• 0244U — oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue
• 81518 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes
  (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy
• 81519 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score
• 81522 — oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes
  (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score

 

To request PA, you may use one of the following methods:

• Web: anthem.com/nv
• Fax: 800-964-3627
• Phone: 844-396-2330

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at availity.com or on the provider website at providers.anthem.com/nv > Login. Contracted and noncontracted providers who are unable to access Availity can call our Provider Services at 844-396-2330 for assistance with PA requirements.

 

ANV-NU-0239-21

Medicaid

We are committed to finding the best ways possible to support our members and providers, and we need your help. Please take a moment to complete the Behavioral Health Areas of Expertise Profile (BHAEP) online survey. This survey is designed to capture supplemental data to enhance our online provider directory and help members find the right behavioral health (BH) provider for their unique needs.

 

Do I have to complete this survey?

All BH practitioners contracted with Anthem Blue Cross and Blue Shield Healthcare Solutions will be asked to complete a survey. However, completion of this survey does not impact your credentialing materials, status, or provider contract. Any representation of a clinical area of interest is based on your self‑disclosure and professional judgment. Please only select those items that fall within the scope of your state‑issued license, clinical experience, and any certifications.

 

Where can I complete the online survey?

You can access the BHAEP online survey at https://tinyurl.com/BHAEP-Survey. You must complete a separate form for each clinical location. Please complete this survey as soon as possible. Your response is critical in helping us match the services you offer with our members’ needs.

 

What if I need assistance?

If you have any questions about completing the survey, please contact Provider Services at 844-396-2330. Any changes or amendments to your provider contract or credentialing must be requested through your Provider Experience representative.

 

We appreciate your continued support.

 

ANV-NU-0243-21

Medicaid

Please continue to check Medicaid Provider Communications & updates at anthem.com/nymedicaiddoc for the latest Medicaid information, including:

• Infusion step therapy retraction notice
• InterQual April 2021 revisions
• New digital provider enrollment tool added to Availity for Nevada

 

ANV-NU-0225-21

ANV-NU-0234-21

ANV-NU-0242-21

Medicare Advantage

 

(Effective 10/01/21)

Anthem Blue Cross and Blue Shield does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at anthem.com/medicareprovider.

 
ABSCRNU-0212-21

Medicare Advantage

 

Help increase your vaccination rates and close gaps-in-care with these tools and strategies

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

 

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases.
• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

 

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

ABSCRNU-0228-21

Medicare Advantage

 

On October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Anthem Blue Cross and Blue Shield. 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.

 

PA requirements will be added for the following codes:

• A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
• A0428 — ambulance service, basic life support, nonemergency transport (BLS)

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at availity.com or on the provider website at anthem.com/medicareprovider > Login. Contracted and noncontracted providers unable to access Availity can call the Provider Services located on the back of their patient’s member ID card for PA requirements.

 

ABSCRNU-0232-21