Please note that the important message below from Bryony Winn – President, Health Solutions – applies to our Commercial, Medicaid and Medicare Advantage programs from Anthem Blue Cross and Blue Shield.

I am pleased to announce that our shareholders voted to approve our parent company's name change from Anthem, Inc. to Elevance Health, Inc. (NYSE Ticker Symbol — ELV) effective
June 28, 2022.

 

Here is what you can expect:

• A bold new vision for the future of health

We chose the name Elevance Health to better reflect our business as we elevate the importance of whole health and advance health beyond healthcare for consumers, their families, and our shared communities. This new vision fuels our transformation from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health. 

• No action is needed by you, and we remain committed to helping you deliver whole-person care for your patients, our customers. Importantly, there is no impact or changes to your contract, reimbursement, or level of support. For your patients, it will not change their plan or coverage or change how they receive their medications. Provider networks will not be changing.

• A more holistic approach to health that improves affordability and outcomes

Bringing together a broad portfolio of health plans, including pharmacy, behavioral, clinical, and complex care provider partners, we can deliver integrated, holistic health solutions to meet the increasing needs of our customers and care provider partners. This includes two notable changes:

• Our healthcare service partners will operate under a new brand called Carelon. This includes Beacon Health Options, AIM Specialty Health_®, CareMore, and IngenioRx. You can find us at Carelon.com.
• IngenioRx, our pharmacy benefit management partner, will become CarelonRx on
  January 1, 2023. This name change will not impact your patient’s benefits, coverage, or how their medications are filled. We will communicate detailed information about this change soon.
• A simpler brand portfolio that makes it easier to do business with us

We have streamlined and simplified the complexity of our health plan and service businesses and reduced the number of brands we have in the market, so our partners and customers clearly understand where we serve, who we serve, and what our brands do.

 

What does this mean for care providers?

We will operate as Anthem Blue Cross or Anthem Blue Cross and Blue Shield in our 14 Blue-licensed markets. Our existing Anthem-branded health plans are not changing and will continue to operate in their current states. There will be no impact to plans, coverage, or level of support.

 

Looking forward together

As your partner, we will continue to keep you updated with new information as soon as it becomes available. In the meantime, you can visit us at ElevanceHealth.com or contact your provider representative with any questions.

 

Thank you for joining us on this exciting path forward as we reimagine what is possible for every moment of health.

 

Sincerely,

Bryony Winn

President, Health Solutions

 

NVBCBS-CDCRCM-001863-22

GABCBS-CRCM-001855-22

This communication applies to the Medicaid program from Anthem Blue Cross and Blue Shield Healthcare Solutions and the Medicare Advantage and Commercial programs from

Anthem Blue Cross and Blue Shield (Anthem) in Nevada.

 

Did you know that Provider Relations has been redesigned into the Provider Experience team?

 

What’s new?

• Provider Experience works all lines of business: Commercial, Medicaid, and Medicare.
• Provider Experience now focuses on two things:
  1. Education and training:
     • Onboarding for new providers
     • Appropriate channels for claim questions
     • Provider self-service tools on Availity
     • How to submit demographic changes for the provider and/or organization
     • Ensuring providers remain up to date about what’s new
  2. Assisting in issue resolution by:
     • Responding to inquiries within 48 to 72 hours
     • Increasing focus on understanding and resolving inquiries
     • Bettering service across all lines of business to reduce points of contact
     • Helping providers when issues are not resolved through standard processes

 

Need to reach us? Provider Experience has an easy-to-use Contact Us page

Not sure who your Provider Experience consultant is? Don’t worry! 

 

We have a new tool that allows you to submit questions to our team directly at https://providers.anthem.com/nevada-provider/contact-us/email.

 

Your question will be automatically routed to a Provider Experience consultant, who will assist you within 48 hours.

 

ANV-NU-0338-22

This communication applies to the Medicare Advantage and Commercial programs from

Anthem Blue Cross and Blue Shield (Anthem) in Nevada.

 

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.

 

Unfortunately, there are certain non-participating labs that are offering to waive or cap co-payments, coinsurance, or deductibles to our members 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 Providers Overview. Select Find Resources in Your State and pick Nevada. From the Provider Home tab, select the enter button from the blue box on the left side of page titled Find a Doctor.

 

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 provides 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:

 

·       Allergy program ·       Cancer testing ·       Cardiovascular disease ·       Companion diagnostics ·       Dermatology ·       Diabetes ·       DNA testing ·       Endocrine disorders ·       Esoteric coagulation ·       Gastroenterology

·       Genetic testing ·       Genetic counseling ·       Genomics ·       Human Leukocyte Antigens (HLA) lab for national marrow donor program ·       Hematopathology ·       Infectious disease ·       Immunology ·       Liver disease ·       Kidney disease

·       Medical drug monitoring ·       Molecular diagnostics ·       Newborn screening ·       Pain management ·       Pathology expertise with range of subspecialties ·       Pharmacogenomics ·       Preimplantation genetic diagnosis ·       Reproductive health

·       Obstetrics/ gynecology ·       Oncology ·       Toxicology ·       Whole exome sequencing ·       Virology ·       Women’s health ·       Urology

 

Note: This relationship with LabCorp does not affect network hospital-based lab service providers, or contracted pathologists.

 

To find a LabCorp location near you, go to www.LabCorp.com or call one of the phone numbers below.

 

For information about specialized assays or about requirements for special collection kits and specimen handling, call LabCorp at 303-792-2600 or toll free at 888-LABCORP (888-522-2677).

 

* LabCorp is an independent company providing lab services on behalf of Anthem.

NVBCBS-CRCM-001719-22

CMS routinely issues revisions to the average sales price (ASP) fee schedules regarding drug pricing. CMS is supplying the third-quarter fee schedule with an effective date of July 1, 2022.  This will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on August 1, 2022. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

 

NVBCBS-CM-002061-22

Current provider directory information helps Anthem Blue Cross and Blue Shield members find the most up-to-date information available. As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.

 

If changes are needed, please take the time to update your information by submitting updates and corrections to us on our online Provider Maintenance Form. Online update options include:

• Adding/changing an address location
• Name change
• Tax ID changes
• Provider leaving a group or a single location
• Phone/fax number changes
• Closing a practice location

 

Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

 

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.

 

MULTI-BCBS-COMM-002040-22-CPN1911

We are enhancing our outpatient facility editing to help align with correct coding guidelines for usage of HCPCS code G0463. The code description for G0463 is “hospital outpatient clinic visit or assessment and management of a patient”. Based on this code description, HCPCS code G0463, should only be billed with revenue codes which support the billing of clinic visits/assessment & management services. When G0463 is billed with an inappropriate revenue code, it will be denied. For assistance with coding guidelines, the National Uniform Billing Committee (NUBC) is a valuable resource.

 

MULTI-BCBS-COMM-002028-22-CPN1882

 

3072F: new language about two-year compliance.

The Comprehensive Diabetes Care HEDIS^® measure Retinal Eye Exam (DRE) valuates the percent of adult members ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.

Changes to 3072F

The definition for the code 3072F (negative for retinopathy) has been redefined to low risk for retinopathy (no evidence of retinopathy in the prior year). This can be particularly confusing because it would not be used at the time of the exam. It would be used the following year, along with the exam coding for the current year, to indicate that retinopathy was not present the previous year.

A simpler coding solution

Using these three codes count toward the DRE measurement if they are billed in the current measurement year or the prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years:

2023F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)
2025F	7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy (DM)
2033F	Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed: without evidence of retinopathy (DM)

For more about diabetic retinopathy, visit CMS.gov or use this link to read more. 

Meeting the measurement for all diabetes care

These exams are also important in evaluating the overall health of diabetic patients, as well as meeting the Comprehensive Diabetes Care HEDIS measure:

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (> 9.0%)
• HbA1c control (< 8.0%)
• Retinal Eye exam performed
• Blood Pressure control (< 140/90 mm Hg)

 

Record your efforts in the member’s medical records for the HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test, and the estimated glomerular filtration rate test. Meeting the mark and closing gaps in care is key to good health outcomes.

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

MULTI-BCBS-CM-002331-22-CPN1921

 

In a recent study published by Pediatrics, 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% in patients 5 to 9 years. Increases from 1% in children aged 13 to 17 to 2.6% for those aged 5 to 9 years were observed.

 

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

 

HEDIS^® measure WCC looks at the percentage of members, 3 to 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

 

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.

 

MULTI-BCBS-CM-002326-22-CPN1916

Medicaid

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

• Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines
• Prior authorization updates for medications billed under the medical benefit
• Updates for medication codes billed under the medical benefit

Medicaid

 

Providers have asked how they can make requests to the state to add non-covered codes. We have recently created a new process to make these requests:

1. Send an email request to Erin Lynch, Chief of the Medical Programs Unit, at erin.lynch@dhcfp.nv.gov:
   • Your request should include the codes that are not currently covered as well as the reasons they should be covered. Please also include any supporting documentation.
2. After Erin Lynch’s team reviews the request, you may receive a letter inviting you to present your request in front of the Medical Care Advisory Committee (MCAC):
   • Your request will be further reviewed, researched, and vetted prior to being brought before the legislative session for consideration and possible budget approval.

 

If you have questions, please contact Erin Lynch at erin.lynch@dhcp.nv.gov.

 

ANV-NU-0339-22

Medicaid

 

This communication applies to the Medicaid program from Anthem Blue Cross and Blue Shield Healthcare Solutions and the Medicare Advantage and Commercial programs from

Anthem Blue Cross and Blue Shield (Anthem) in Nevada.

 

Did you know that Provider Relations has been redesigned into the Provider Experience team?

 

What’s new?

• Provider Experience works all lines of business: Commercial, Medicaid, and Medicare.
• Provider Experience now focuses on two things:
  1. Education and training:
     • Onboarding for new providers
     • Appropriate channels for claim questions
     • Provider self-service tools on Availity
     • How to submit demographic changes for the provider and/or organization
     • Ensuring providers remain up to date about what’s new
  2. Assisting in issue resolution by:
     • Responding to inquiries within 48 to 72 hours
     • Increasing focus on understanding and resolving inquiries
     • Bettering service across all lines of business to reduce points of contact
     • Helping providers when issues are not resolved through standard processes

 

Need to reach us? Provider Experience has an easy-to-use Contact Us page

Not sure who your Provider Experience consultant is? Don’t worry! 

 

We have a new tool that allows you to submit questions to our team directly at https://providers.anthem.com/nevada-provider/contact-us/email.

 

Your question will be automatically routed to a Provider Experience consultant, who will assist you within 48 hours.

 

ANV-NU-0338-22

Medicaid

 

Effective August 1, 2018, presumptive drug screens are limited to one per day with a maximum of 20 tests per 12-rolling months. Only three definitive drug screens are permitted per recipient per 12-rolling months. Should more than 20 presumptive screens or more than three definitive screens be needed in 12-rolling months, a prior authorization is required. Claims paid in excess of these limits, without an approved prior authorization, are subject to recoupment.

 

The impacted provider types (PTs) are: 12 (Hospital, outpatient), 17 (Special clinics), 20 (Physician, M.D., Osteopath, D.O.), 24 (Advanced practice registered nurse), 43 (Laboratory, pathology), 60 (School based), 74 (Nurse midwife) and 77 (Physician’s assistant).

 

Medicaid Services Manual (MSM) Chapter 800 Laboratory Services has been updated with the following information:

 

Section 803.1A coverage and limitations

Drug screening and testing:

• Drugs or drug classes for which screening is performed should only reflect those likely to be present based on the recipient’s medical history, current clinical presentation, or risk potential for abuse and diversion.
• Each drug or drug class being tested for must be indicated by the referring physician in a written order and reflected in the patient’s medical record. This information must be patient-specific and accurately reflect the need for each test and must include the specific drugs being screened including recipient diagnosis.
• Current coding for testing of drugs relies on a structure of screening (known as presumptive screening) and may be followed by quantitative measurements (known as definitive testing) that identifies the specific drug or drugs and quantity in the recipient:
• Only one presumptive test performed by direct observation or instrument assisted direct observation or instrument chemistry analyzers may be billed per recipient per day within a maximum of 20 presumptive test per 12-rolling months.
• If the recipient should require more than 20 presumptive tests per 12-rolling months, a prior authorization is required.
• Only three definitive drug tests are permitted per recipient per 12-rolling months.
• Definitive testing is only covered to confirm an unexpected result or identify drugs or metabolites that cannot be detected on a presumptive drug screen.
• Definitive testing should be based on the recipient’s presentation and history and only include what is needed for safe pain management.
• Standing orders for presumptive drug screens may be utilized but must be individualized for each member, signed, and dated by the treating practitioner and updated every 30 days. Standing orders are not permitted for definitive drug screens. Web announcement 1713 October 18, 2018.
• Procedure codes should be reported with a quantity of one per episode of care, regardless of the number of collection/testing items used, the number of procedures, and/or the drug classes screened.
• Testing for the same drug with a blood and urine specimen simultaneously is not covered.
• Drug screening for pre-employment or employment purposes, medicolegal, and/or court ordered that do not meet medical necessity and/or drug screenings for participation in school or military are not covered.
• Routine drug screening is not covered unless used in conjunction with an extended course of treatment for substance use disorders. Specific intervals, at which recipient test should be performed, based on their individual needs, must be documented in the member’s medical record with their treatment plan.
• Drug confirmation tests are not eligible to be separately reported under any procedure code, unlisted, or otherwise

Information follows web announcement 1713 from the State of NV and can be found in the Medicaid Service Manual (MSM) Chapter 800 Laboratory Services: https://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSM/C800/Chapter800

 

If you have questions about this communication, contact your Provider Services at 844-396-2330 or use the Contact Us at the bottom of our provider website (https://providers.anthem.com/nv) for up-to-date contact information.

 

ANV-NU-0337-22

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 https://www.anthem.com/provider/policies/clinical-guidelines/search.

 

Notes/updates:

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

• *CG-LAB-20 — Thyroid Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing
• *CG-LAB-21 — Serum Iron Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing
• *LAB.00043 — Immune Biomarker Tests for Cancer:
  • Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
  • Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
  • The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
    • Endometrial receptivity analysis
    • Sperm-capacitation test
    • Sperm deoxyribonucleic acid (DNA) fragmentation test
    • Sperm penetration assay
    • Uterine natural killer (uNK) cells test
  • *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
    • Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease
    • Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary
    • Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document
  • *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
    • Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications
  • *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
    • Revised Position Statement to include the prevention of lymphedema
  • *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
    • The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications
  • *TRANS.00038 — Thymus Tissue Transplantation:
    • Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue

 

Effective June 11, 2022, Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) will begin using the AIM Specialty Health^®1 Clinical Appropriateness Guidelines for medical necessity review of the below services. Please note, the Anthem Utilization Management team will complete these reviews using the AIM Clinical Appropriateness Guidelines:

• Musculoskeletal guidelines
  • Spine surgery
  • Joint surgery
  • Small joint surgery
  • Sacroiliac joint fusion
• Sleep disorder management guideline
• Rehabilitative services
  • Occupational therapy
  • Physical therapy
  • Speech therapy

 

Medical Policies

On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These guidelines take effect
June 11, 2022.

Publish date	Medical policy number	Medical Policy title	New or revised
04/13/2022	*LAB.00043	Immune Biomarker Tests for Cancer	New
04/13/2022	*LAB.00044	Saliva-based Testing to Determine Drug-Metabolizer Status	New
04/13/2022	*LAB.00045	Selected Tests for the Evaluation and Management of Infertility	New
04/13/2022	*LAB.00046	Testing for Biochemical Markers for Alzheimer’s Disease	New
04/13/2022	*RAD.00067	Quantitative Ultrasound for Tissue Characterization	New
04/13/2022	*SURG.00160	Implanted Port Delivery Systems to Treat Ocular Disease	New
03/25/2022	*TRANS.00038	Thymus Tissue Transplantation	New
04/13/2022	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
04/1/2022	SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
02/24/2022	SURG.00036	Fetal Surgery for Prenatally Diagnosed Malformations	Revised
04/13/2022	SURG.00096	Surgical and Ablative Treatments for Chronic Headaches	Revised
04/13/2022	*SURG.00154	Microsurgical Procedures for the Prevention or Treatment of Lymphedema	Revised

 

Clinical UM Guidelines

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Nevada Medicaid members on March 24, 2022. These guidelines take effect June 11, 2022.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
04/13/2022	*CG-LAB-20	Thyroid Testing	New
04/13/2022	*CG-LAB-21	Serum Iron Testing	New
04/13/2022	CG-ANC-03	Acupuncture	Revised
04/13/2022	CG-GENE-14	Gene Mutation Testing for Cancer Susceptibility and Management	Revised
04/13/2022	CG-MED-73	Hyperbaric Oxygen Therapy (Systemic/Topical)	Revised
04/13/2022	CG-SURG-36	Adenoidectomy	Revised
02/24/2022	CG-SURG-86	Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection	Revised

 

 

ANV-NU-0334-22

Medicaid

On November 19, 2021, January 4, 2022, and February 25, 2022, 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 Healthcare Solutions. 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
June 11, 2022	*ING-CC-0211	Kimmtrak (tebentafusp-tebn)	New
June 11, 2022	*ING-CC-0210	Enjaymo (sutimlimab-jome)	New
June 11, 2022	*ING-CC-0213	Voxzogo (vosoritide)	New
June 11, 2022	*ING-CC-0212	Tezspire (tezepelumab-ekko)	New
June 11, 2022	*ING-CC-0086	Spravato (esketamine) Nasal Spray	Revised
June 11, 2022	ING-CC-0157	Padcev (enfortumab vedotin)	Revised
June 11, 2022	ING-CC-0125	Opdivo (nivolumab)	Revised
June 11, 2022	ING-CC-0119	Yervoy (ipilimumab)	Revised
June 11, 2022	*ING-CC-0099	Abraxane (paclitaxel, protein bound)	Revised
June 11, 2022	ING-CC-0120	Kyprolis (carfilzomib)	Revised
June 11, 2022	ING-CC-0126	Blincyto (blinatumomab)	Revised
June 11, 2022	ING-CC-0129	Bavencio (avelumab)	Revised
June 11, 2022	*ING-CC-0090	Ixempra (ixabepilone)	Revised
June 11, 2022	ING-CC-0110	Perjeta (pertuzumab)	Revised
June 11, 2022	ING-CC-0115	Kadcyla (ado-trastuzumab)	Revised
June 11, 2022	ING-CC-0108	Halaven (eribulin)	Revised
June 11, 2022	*ING-CC-0033	Xolair (omalizumab)	Revised
June 11, 2022	*ING-CC-0043	Monoclonal Antibodies to Interleukin-5	Revised
June 11, 2022	ING-CC-0038	Human Parathyroid Hormone Agents	Revised
June 11, 2022	*ING-CC-0186	Margenza (margetuximab-cmkb)	Revised
June 11, 2022	*ING-CC-0124	Keytruda (pembrolizumab)	Revised
June 11, 2022	*ING-CC-0078	Orencia (abatacept)	Revised
June 11, 2022	ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
June 11, 2022	ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
June 11, 2022	*ING-CC-0029	Dupixent (dupilumab)	Revised
June 11, 2022	*ING-CC-0208	Adbry (tralokinumab)	Revised
June 11, 2022	*ING-CC-0209	Leqvio (inclisiran)	Revised
June 11, 2022	*ING-CC-0166	Trastuzumab Agents	Revised
June 11, 2022	*ING-CC-0107	Bevacizumab for Non-ophthalmologic Indications	Revised

 

ANV-NU-0331-22

Medicare Advantage

 

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

• New specialty pharmacy medical step therapy requirements

Medicare Advantage

 

Beginning with claims processed on or after August 1, 2022, Anthem Blue Cross and Blue Shield will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT^® codes 99381 to 99397) is billed with a problem-oriented E/M service (CPT codes 99202 to 99215) and appended with Modifier 25 (for example, CPT code 99393 billed with CPT code 99213 to 99225).

 

According to the American Medical Association (AMA) CPT Guidelines, E/M services must be “significant and separately identifiable” in order to appropriately append Modifier 25. Based upon review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.

 

Providers that believe their medical record documentation supports a significant and separately identifiable E/M service should follow the Claims Payment Dispute process (including submission of such with the dispute) as outlined in the provider manual.

 

If you have questions on this program, contact your contract manager or Provider Experience.

 

 

ABSCRNU-0342-22

Medicare Advantage

 

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

 

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.

 

Unfortunately, there are certain non-participating labs that are offering to waive or cap co-payments, coinsurance, or deductibles to our members 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 Providers Overview. Select Find Resources in Your State and pick Nevada. From the Provider Home tab, select the enter button from the blue box on the left side of page titled Find a Doctor.

 

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 provides 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:

 

· Allergy program · Cancer testing · Cardiovascular disease · Companion diagnostics · Dermatology · Diabetes · DNA testing · Endocrine disorders · Esoteric coagulation ·  Gastroenterology

· Genetic testing · Genetic counseling · Genomics · Human Leukocyte Antigens (HLA) lab for national marrow donor program · Hematopathology · Infectious disease · Immunology · Liver disease · Kidney disease

· Medical drug monitoring · Molecular diagnostics · Newborn screening · Pain management · Pathology expertise with range of subspecialties · Pharmacogenomics · Preimplantation genetic diagnosis · Reproductive health

· Obstetrics/ gynecology · Oncology · Toxicology · Whole exome sequencing · Virology · Women’s health · Urology

 

Note: This relationship with LabCorp does not affect network hospital-based lab service providers, or contracted pathologists.

 

To find a LabCorp location near you, go to www.LabCorp.com or call one of the phone numbers below.

 

For information about specialized assays or about requirements for special collection kits and specimen handling, call LabCorp at 303-792-2600 or toll free at 888-LABCORP (888-522-2677).

 

* LabCorp is an independent company providing lab services on behalf of Anthem.

NVBCBS-CRCM-001719-22

Medicare Advantage

 

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

 

In an effort to deliver on Anthem’s purpose to improve the health of humanity, we now have a program for in-home patient care for acute conditions.

 

Anthem’s Hospital in Home program can advise capable, innovative hospital partners in developing their own hospital in home programs. Once implemented, patients can recover in a more comfortable environment, allowing hospitals to keep beds available for patients with more complex needs.

 

Inpatient level of care in the home can be a welcome alternative to traditional hospital settings. Patients may find acute care at home to be more convenient and less stressful, and studies have shown acute care at home can be safe and allow for smoother transition to self-care management after the acute illness. Hospital in Home clinical trials demonstrate a 25% decrease in readmissions and a 50% reduction in time spent in bed.¹

 

Anthem’s Hospital in Home program has a set of minimum requirements that are designed to promote patient safety. These requirements include aspects of the member’s home environment, the clinical scenario, remote monitoring capabilities, and plans for program evaluation.

 

Please contact your Anthem contracting representative to learn more about Anthem’s Hospital in Home program.

 

1  Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of internal medicine, 172(2), 77–85. https://doi.org/10.7326/M19-0600.

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Medicare Advantage

 

The Cancer Care Navigator (CCN) program is a comprehensive cancer support solution for oncologists and Anthem Blue Cross and Blue Shield (Anthem) members who are at high risk for complications during treatment. This program is aimed at helping to simplify the complexities of cancer care for members.

 

Practices are given a single point of contact to connect the practice to the right people at Anthem to help lessen administrative burdens. CCN also gives the practice access to Anthem’s advanced predictive analytics to help identify patients at high risk for complications, in turn allowing providers the opportunity to take preventive action and guide targeted interventions.

 

Patients are provided with a wealth of support through supplemental services (dietitians, pharmacists, etc.), medication adherence assistance, individualized care plans, and goal setting, as well as after-hours telephonic and digital support.

 

CCN is the ultimate support service to improve the care experience and quality of life to allow patients time to focus on overall health and well-being. Please feel free to reach out to the CCN team at 866-649-0669.

 

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