June 1, 2024

June 2024 Provider Newsletter

Contents

AdministrativeCommercialJune 1, 2024

CAA: Review your online provider directory information

AdministrativeCommercialMedicare AdvantageMedicaidJune 1, 2024

Availity Essentials single claim submission response reports

AdministrativeCommercialJune 1, 2024

Implant — Facility Editing update

AdministrativeMedicare AdvantageMedicaidJune 1, 2024

Inaccurate laterality and diagnosis combination

Digital SolutionsCommercialMedicare AdvantageMedicaidMay 23, 2024

Digital RFAI Availity training

Digital SolutionsMedicare AdvantageMedicaidMay 15, 2024

Introducing new functionality for non-medical providers

Education & TrainingCommercialMedicare AdvantageMedicaidJune 1, 2024

June is LGBTQIA+ Pride Month

Education & TrainingCommercialMedicare AdvantageMedicaidMay 23, 2024

You are invited: Thriving, not just surviving: navigating challenging times as a clinician

Policy UpdatesMedicaidMay 7, 2024

Carelon Medical Benefits Management, Inc. updates

Policy UpdatesMedicaidMay 2, 2024

MCG Care Guidelines 27th edition update

Medical Policy & Clinical GuidelinesCommercialApril 30, 2024

MCG Care Guidelines 28th edition

Medical Policy & Clinical GuidelinesMedicare AdvantageMay 1, 2024

MCG Care Guidelines 28th edition

Medical Policy & Clinical GuidelinesMedicare AdvantageMay 7, 2024

Clinical Criteria updates

Medical Policy & Clinical GuidelinesMedicaidMay 13, 2024

Medical Policies and Clinical Utilization Management Guidelines update

Medical Policy & Clinical GuidelinesCommercialMay 28, 2024

Updates to Carelon Post-Acute Care Clinical Appropriateness Guidelines

Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageMay 3, 2024

Carelon Medical Benefits Management, Inc. genetic testing code updates

Prior AuthorizationCommercialJune 1, 2024

Expansion of Carelon Medical Benefits Management, Inc. programs

Products & ProgramsMedicaidJune 1, 2024

Bringing whole person care to sickle cell disease management

PharmacyMedicare AdvantageJune 1, 2024

Addressing medication adherence gaps

PharmacyMedicare AdvantageJune 1, 2024

Improving patient outcomes with statin therapy in diabetes

PharmacyCommercialJune 1, 2024

Pharmacy information available on our provider website

Quality ManagementCommercialApril 19, 2024

Improving patient health and digital literacies

Quality ManagementCommercialMedicaidMay 15, 2024

Tips to Improve Adolescent Immunization (IMA) Rates

Quality ManagementMedicaidJune 1, 2024

Complex Care Management program

Quality ManagementCommercialMay 6, 2024

Enhance patient access to digital health resources

Quality ManagementCommercialMedicaidMay 7, 2024

Take action to improve adolescent immunizations rates

NVBCBS-CDCRCM-059385-24

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

AdministrativeCommercialJune 1, 2024

CAA: Review your online provider directory information

Please review your online provider directory information on a regular basis to ensure that it’s correct. Access your online provider directory information by visiting anthem.com/provider, then at the top of the webpage, choose Find Care. Review your information and let us know if any of your directory information has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

  • Updating provider demographic information for all assigned payers in one location.
  • Attesting to and managing current provider demographic information.
  • Monitoring submitted demographic updates in real-time with a digital dashboard.
  • Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-058919-24

AdministrativeCommercialMedicare AdvantageMedicaidJune 1, 2024

Availity Essentials single claim submission response reports

Does your organization submit single claim submissions online to Availity Essentials? This feature is a no-cost option to submit your claims, but like all claim submissions, it’s important to review the response reports to ensure your claim has been accepted.

How do I view my response reports?

Your organization’s Availity administrator will need to assign the electronic data interchange (EDI) management role to users who submit online claim submissions. Even though the claims are submitted without using EDI software or a vendor, online claim submissions are still considered EDI transactions that will create response reports.

Once the role has been assigned, the user will have access to the EDI clearinghouse menu located under the Claims & Payments menu. The three tiles used are listed below:

  • Send and receive EDI files — The response files will be in the receive folder.
  • File restore — Availity will archive your response files after 60 days; use this option to restore your reports.
  • EDI reporting preferences — Select text > Human readable format. The other formats are only used for EDI software.

What kind of response reports do I need to view?

  • File acknowledgments — shows your claim has been received
  • Immediate batch response — acknowledges accepted claim and identifies if rejected due to HIPAA and/or payer-specific edits
  • Delayed payer reports — Certain policies will go through a second level of editing for the payer; This report will return if that is the case.

We are here to help

Availity Essentials offers on-demand recorded training and documentation to assist with reviewing your response reports:

  • Log in to Availity Essentials and select Help & Training > Get Trained.
  • Use the catalog filter and select EDI Clearinghouse; several courses will display for you to enroll in and view.
  • Use the EDI Companion Document to view the Setup EDI Reporting Preferences Chapter.
  • Contact Availity Client Services at 800-282-4548 Monday through Friday from 8 a.m. until 8 p.m.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CDCRCM-057164-24-CPN54585

AdministrativeCommercialJune 1, 2024

Implant — Facility Editing update

Effective for all claims received on and after September 1, 2024, Anthem is updating its outpatient facility editing system to deny the following HCPCS codes when billed with revenue code 0278:

A0001–A2012

C1052

A4212

C1600–C1604

A4215–A4217

C1761

A4220–A4221

C1765

A4290

C1787

A4305–A4306

C1748

A4314–A4316

C1818

A4338–A4351

Q4279

A4364

Q4287–Q4304

A4461

V2785

This facility editing update is supported by Anthem’s Implants — Facility commercial reimbursement policy. If you believe you have received a denial in error, please follow Anthem’s standard claim dispute process.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-057929-24-CPN57522

AdministrativeMedicare AdvantageMedicaidJune 1, 2024

Inaccurate laterality and diagnosis combination

Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT® or HCPCS code must correspond to the laterality within the ICD-10 description.

On a CMS 1500 form, for professional submitted claims processed July 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis.

See examples below

Reported diagnosis: E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral):

  • Billed CPT code: 67228-RT Treatment of extensive or progressive retinopathy (for example, diabetic retinopathy), photocoagulation.
  • Determination: It is not appropriate to report the RT modifier when the laterality of bilateral is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.

Reported diagnosis: S91.011A (Laceration without foreign body, right ankle, initial encounter):

  • Billed CPT code: 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation)
  • Determination: It is not appropriate to report a LT modifier when the laterality of right is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed.

Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

EOB message

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex codes: v19 and 00V19

If you have questions about this communication or need assistance, contact your provider relationship account manager. We are committed to a future of shared success.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CDCR-057418-24-CPN52942

Digital SolutionsCommercialMedicare AdvantageMedicaidMay 23, 2024

Digital RFAI Availity training

In collaboration with Availity, we’ve developed self-paced training for your organization’s administrators about how to update the Medical Attachment registration.

Care providers enrolled in the Medical Attachments applications on Availity Essentials can now take advantage of faster claims processing through Digital Request for Additional Information (Digital RFAI). Receive digital notifications faster when additional documents are needed to process member claims.

Availity administrators can use this link to view the training on demand for Digital Request for Additional Information: Pre-check for Administrators.

We have also developed an enhanced training session for associates responsible for sending attachments. This training walks through the Attachments Dashboard and many of the unique features that make the dashboard most efficient.

Use thislink to register for the live trainings or to view the training on demand for Learn How to Submit Digital Requests for Additional Information (RFAI).

Register today!

  • June 11, 2024, from 2:30 to 3:30 p.m. ET
  • June 13, 2024, from 2:30 to 3:30 p.m. ET.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CDCRCM-057579-24-CPN57402

Digital SolutionsMedicare AdvantageMedicaidMay 15, 2024

Introducing new functionality for non-medical providers

Save time and get faster results by using Availity Essentials to submit disputes for atypical care providers.

As part of our ongoing efforts to optimize and enhance the Claims Status application in Availity Essentials, we recently launched the ability for non-medical/atypical care providers — such as providers of non-emergency transportation, case management, or environmental modifications — to use the Dispute functionality in the enhanced Claims Status app. This new functionality allows atypical care providers to be more efficient and accurate in their dispute submission process.

Below are a few simple and important steps and reminders to follow for the best experience and results.

First step

Register with Availity Essentials

Non-medical/atypical care providers can submit a dispute using Availity Essentials. Care providers need to first register an organization with Availity Essentials, ensuring an administrator is chosen and their provider information — including tax ID — is added to Manage My Organization.

Once the organization is set up as Non-Medical/Atypical on Availity Essentials, it can use various functions, such as submitting disputes. Atypical care providers do not use an NPI to bill claims; therefore, it's important that the setup is completed.

Second step

Go to the Claims Status app:

  • Navigate from the home page to Claims & Payments > Claim Status > select your organization and payer > Claim Status Inquiry page will open.
  • When Manage My Organization has been completed, you can select the care provider from the drop-down menu and the tax ID field will display.
  • Complete an inquiry by entering the required fields and selecting Submit for requested claims to display.

Third step

Select Dispute

To complete a dispute:

  • Locate the claim and, if there is an option to appeal, select Dispute to initiate.
  • Select Go to details to be navigated to the Appeals Application.
  • Locate your initiated dispute and select the action menu to complete the dispute request.
  • Choose the request reason, upload supporting documents, and submit the request.

Once completed, your progress will appear in the Notifications Center on the Availity Essentials home page when Web is selected in the contact field.

Explore training and resources

We are here to support you along the way through on-demand training and resources.

Availity Essentials offers keyword search assistance with the option to attend live or recorded demos:

  • On the Availity Essentials home page, select Help & Training, then select Get Trained to register for upcoming live and recorded training demos for all Availity Essentials capabilities.
  • Use the search bar to locate specific appeals training.
  • The Availity Learning Center user guide will assist with how to locate training.

For questions, contact Availity Client Service:

  • Online: Help & Training > Availity Support > Contact Support > Create a case or Chat with Support
  • By phone: Call 800-AVAILITY (282-4548) Monday through Friday from 8 a.m. to 8 p.m. Eastern time

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CDCR-054925-24-CPN54404

Education & TrainingCommercialMedicare AdvantageMedicaidJune 1, 2024

June is LGBTQIA+ Pride Month

We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for providers.

In recognition of June as National LGBTQIA+ Pride Month, we are introducing three eLearning tools on LGBTQIA+ health, available on the My Diverse Patients site. This site offers a comprehensive repository of resources for providers to help support the needs of diverse patients and address healthcare disparities. Multiple free continuing medical education (CME) courses are available, with CME credits offered through the American Academy of Family Physicians (AAFP).

For the month of June, our featured eLearning experience and resources are:

  • My Inclusive Practice — Improving Care for LGBTQIA+ Patients — a CME credit hour provider training. Course benefits:
    • Understand the fears and anxieties LGBTQIA+ patients often feel about seeking medical care.
    • Learn key health concerns of LGBTQIA+ patients.
    • Develop strategies for providing effective healthcare to LGBTQIA+ patients.
    • Review ideas for creating a welcoming office environment.
  • National LGBTQIA+ Health Education Center — Resources & Tools:
    • The National LGBTQIA+ Health Education Center provides educational programs, resources, and consultation to healthcare organizations with the goal of optimizing quality, cost‑effective healthcare for lesbian, gay, bisexual, and transgender people.
  • Pre-Exposure Prophylaxis (PrEP) Action KitResources & Tools:
    • The PrEP Action Kit includes clinical resources to help providers incorporate PrEP into their practices. Including helpful resources such as tips on taking a comprehensive sexual history, frequently asked questions about PrEP, and a pocket card about PrEP prescribing and monitoring, this action kit is an essential resource for all providers treating LGBTQIA+ patients or patients at risk of HIV infection.

These courses are designed for doctors (CME credit provided), nurses, health professionals, and medical office staff.

Providers can view these courses on their smartphone, tablet, or computer.

We're pleased to offer these resources as we work together to deliver high-quality, equitable healthcare.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-ALL-CDCRCM-059067-24-CPN58594

Education & TrainingCommercialMedicare AdvantageMedicaidMay 23, 2024

You are invited: Thriving, not just surviving: navigating challenging times as a clinician

Join us to hear from a diverse panel of experienced professionals from Motivo and Anthem. During this interactive webinar, we will explore the recent research on the impact mental health has on providers and share insights into support services like counseling, stress management, and self-care resources.

Register today for the Thriving Not Just Surviving: Navigating Challenging Times as a Clinician forum hosted by Anthem and Motivo for Anthem providers.

Wednesday, June 26, 2024 | 3:30 to 5 p.m. ET

Please register for this event using this link: Forum registration

Recognizing the emotional stress providers often experience, this forum aims to deepen the discussion on mental health and the importance of prioritizing clinician’s self-care.

Together, we will work to foster a culture of understanding and support not just for clients, but for providers. By doing so, we work collaboratively for the health and wellbeing of all Americans and the communities in which we live and serve.

Each forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, have difficult and productive conversations, learn about valuable resources, and improve the health and wellbeing of our communities.

Also, join us in November, National Family Caregivers Awareness Month, for a webinar dedicated to supporting caregivers.

We are committed to working together to achieve improved outcomes and foster genuine collaboration with our care provider partners.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CDCRCM-057135-24-CPN57088

Policy UpdatesMedicaidMay 7, 2024

Carelon Medical Benefits Management, Inc. updates

Effective on June 30, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates for medical necessity review will apply for Anthem:

  • Genetic testing:
    • Hereditary Cancer Testing
    • Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
    • Genetic Testing for Inherited Conditions

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CD-050472-24-CPN49779

Policy UpdatesMedicaidMay 2, 2024

MCG Care Guidelines 27th edition update

Effective June 1, 2024, Anthem will transition from CG-BEH-02 (Adaptive Behavioral Treatment) and MCG W0153 (Behavioral Health Care [BHG] Applied Behavioral Analysis), to MCG B-806-T (Behavioral Health Care [BHG] Applied Behavioral Analysis [Original MCG Guideline]), for medical necessity and clinical appropriateness reviews.

If you have questions, contact Provider Services at 844-396-2330.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CD-046940-23-CPN46739

Medical Policy & Clinical GuidelinesCommercialApril 30, 2024

MCG Care Guidelines 28th edition

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

  • Behavioral Health Care (BHG):
    • The goal length of stay (GLOS) has been changed in two guidelines in the 28th edition of Behavioral Health Care.
  • Inpatient & Surgical Care (ISC):
    • The goal length of stay (GLOS) has been changed in a total of 72 Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care. In medical Optimal Recovery Guidelines, the GLOS has been changed in 37 guidelines, and the GLOS has been changed in 35 surgical Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care.
  • General Recovery Care (GRG):
    • Benchmark length of stay (BLOS) has been refined in the 28th edition of General Recovery Care.
  • Recovery Facility Care (RFC):
    • A total of one guideline has been removed from the 28th edition of Recovery Facility Care.
  • Chronic Care (CCG):
    • A total of 10 guidelines have been moved in the 28th edition of Chronic Care.

If you have questions, please contact the provider service number on the back of the member's ID card.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-056557-24-SRS56156

Medical Policy & Clinical GuidelinesMedicare AdvantageMay 1, 2024

MCG Care Guidelines 28th edition

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive.

  • Behavioral Health Care (BHG)
    • The goal length of stay (GLOS) has been changed in 2 guidelines in the 28th edition of Behavioral Health Care.
  • Inpatient & Surgical Care (ISC)
    • The goal length of stay (GLOS) has been changed in a total of 72 Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care. In medical Optimal Recovery Guidelines, the GLOS has been changed in 37 guidelines and the GLOS has been changed in 35 surgical Optimal Recovery Guidelines, in the 28th edition of Inpatient & Surgical Care.
  • General Recovery Care (GRG)
    • The benchmark length of stay (BLOS) has been refined in the 28th edition of General Recovery Care.
  • Chronic Care (CCG)
    • A total of 10 guidelines have been moved in the 28th edition of Chronic Care.

For questions, please contact the provider service number on the back of the member's ID card.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-056697-24-CPN55820

Medical Policy & Clinical GuidelinesMedicare AdvantageMay 7, 2024

Clinical Criteria updates

Effective June 10, 2024

Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. 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 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 providers in your practice and office staff.

Please 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.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date

Clinical Criteria number

Clinical Criteria title

New or revised

June 10, 2024

*CC-0258

iDoseTR (travoprost Implant)

New

June 10, 2024

*CC-0259

Amtagvi (lifleucel)

New

June 10, 2024

*CC-0260

Nexobrid (anacaulase-bcdb)

New

June 10, 2024

*CC-0199

Empaveli (pegcetacoplan)

Revised

June 10, 2024

*CC-0041

Complement Inhibitors

Revised

June 10, 2024

CC-0128

Tecentriq (atezolizumab)

Revised

June 10, 2024

CC-0116

Bendamustine agents

Revised

June 10, 2024

CC-0161

Sarclisa (isatuximab-irfc)

Revised

June 10, 2024

CC-0158

Enhertu (fam-trastuzumab deruxtecan-nxki)

Revised

June 10, 2024

CC-0157

Padcev (enfortumab vedotin)

Revised

June 10, 2024

CC-0230

Adstiladrin (nadofaragene firadenovec-vncg)

Revised

June 10, 2024

*CC-0125

Opdivo (nivolumab)

Revised

June 10, 2024

*CC-0119

Yervoy (ipilimumab)

Revised

June 10, 2024

*CC-0099

Abraxane (paclitaxel, protein bound)

Revised

June 10, 2024

*CC-0093

Docetaxel (Taxotere)

Revised

June 10, 2024

*CC-0094

Pemetrexed (Alimta, Pemfexy, Pemrydi)

Revised

June 10, 2024

CC-0130

Imfinzi (durvalumab)

Revised

June 10, 2024

*CC-0088

Elzonris (tagraxofusp-erzs)

Revised

June 10, 2024

*CC-0118

Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)

Revised

June 10, 2024

*CC-0112

Xofigo (Radium Ra 223 Dichloride)

Revised

June 10, 2024

*CC-0123

Cyramza (ramucirumab)

Revised

June 10, 2024

*CC-0131

Besponsa (inotuzumab ozogamicin)

Revised

June 10, 2024

CC-0121

Gazyva (obinutuzumab)

Revised

June 10, 2024

CC-0122

Arzerra (ofatumumab)

Revised

June 10, 2024

CC-0232

Lunsumio (mosunetuzumab-axgb)

Revised

June 10, 2024

CC-0109

Zaltrap (ziv-aflibercept)

Revised

June 10, 2024

CC-0135

Melanoma Vaccines

Revised

June 10, 2024

*CC-0096

Asparagine Specific Enzymes

Revised

June 10, 2024

CC-0120

Kyprolis (carfilzomib)

Revised

June 10, 2024

*CC-0117

Empliciti (elotuzumab)

Revised

June 10, 2024

*CC-0126

Blincyto (blinatumomab)

Revised

June 10, 2024

CC-0113

Sylvant (siltuximab)

Revised

June 10, 2024

CC-0132

Mylotarg (gemtuzumab ozogamicin)

Revised

June 10, 2024

CC-0097

Vidaza (azacitidine)

Revised

June 10, 2024

CC-0129

Bavencio (avelumab)

Revised

June 10, 2024

*CC-0090

Ixempra (ixabepilone)

Revised

June 10, 2024

CC-0110

Perjeta (pertuzumab)

Revised

June 10, 2024

*CC-0115

Kadcyla (ado-trastuzumab)

Revised

June 10, 2024

*CC-0108

Halaven (eribulin)

Revised

June 10, 2024

CC-0089

Mozobil (plerixafor)

Revised

June 10, 2024

CC-0124

Keytruda (pembrolizumab)

Revised

June 10, 2024

*CC-0002

Colony Stimulating Factor Agents

Revised

June 10, 2024

*CC-0212

Tezspire (tezepelumab-ekko)

Revised

June 10, 2024

*CC-0033

Xolair (omalizumab)

Revised

June 10, 2024

*CC-0043

Monoclonal Antibodies to Interleukin-5

Revised

June 10, 2024

*CC-0029

Dupixent (dupilumab)

Revised

June 10, 2024

*CC-0208

Adbry (tralokinumab)

Revised

June 10, 2024

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

June 10, 2024

*CC-0067

Prostacyclin Infusion and Inhalation Therapy

Revised

June 10, 2024

*CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

June 10, 2024

*CC-0064

Interleukin-1 Inhibitors

Revised

June 10, 2024

*CC-0057

Krystexxa (pegloticase)

Revised

June 10, 2024

*CC-0068

Growth Hormones

Revised

June 10, 2024

*CC-0047

Trogarzo

Revised

June 10, 2024

*CC-0078

Orencia (abatacept)

Revised

June 10, 2024

*CC-0107

Bevacizumab for Non-ophthalmologic Indications

Revised

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-058781-24-CPN57659

Medical Policy & Clinical GuidelinesMedicaidMay 13, 2024

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised during Q4 2023. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/provider/policies/clinical-guidelines/search/.

Notes/updates

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

  • MED.00146 - Gene Therapy for Sickle Cell Disease:
    • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for Gene therapy for sickle cell disease
  • RAD.00068 - Myocardial Strain Imaging:
    • Myocardial strain imaging in considered Investigational & Not Medically Necessary for all indications
  • SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation:
    • Reformatted Position Statement and added headers
    • Reformatted Medically Necessary statements to move target treatment areas into criteria
    • Revised Medically Necessary statement for primary dystonia to remove dystonia manifestation types
    • Reformatted Medically Necessary statements for DBS for Parkinson’s, primary dystonia, and OCD
    • Reformatted Medically Necessary statements for epilepsy
    • Revised DBS for epilepsy Medically Necessary statement regarding non-epileptic seizures
    • Revised Position Statement to add revision/replacement Medically Necessary and Investigational & Not Medically Necessary statements for DBS, cortical stimulation, and battery
    • Revised and reformatted Investigational & Not Medically Necessary statements
  • SURG.00097 - Scoliosis Surgery:
    • Revision to Position Statement formatting
    • Added Medically Necessary and Investigational & Not Medically Necessary criteria for revision, replacement, or removal of vertebral body tethering to Position Statement
  • SURG.00142 - Genicular Procedures for Treatment of Knee Pain
    Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain:
    • Revised title
    • Added genicular artery embolization to the scope of document
    • Revised Position Statement to add genicular artery embolization as Investigational & Not Medically Necessary
  • CG-DME-42 - Continuous Glucose Monitoring Devices:
    Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
    • Revised title
    • Moved content related to external insulin pumps to new document CG-DME-51 and automated insulin delivery systems to new document CG-DME-50
    • Revised existing Medically Necessary and Not Medically Necessary statements
  • CG-DME-52 - Continuous Passive Motion Devices in the Home Setting:
    • Use of a continuous passive motion (CPM) device in the home setting is considered Not Medically Necessary for all indications
  • CG-MED-94 - Vestibular Function Testing:
    • Outlines the Medically Necessary and Not Medically Necessary criteria for vestibular function testing
  • CG-SURG-09 - Temporomandibular Disorders:
    • Revised formatting of Medically Necessary statement
    • Revised surgical procedures criteria
    • Added MIRO Therapy to Not Medically Necessary statement
  • CG-SURG-70 - Gastric Electrical Stimulation:
    • Added Medically Necessary and Not Medically Necessary criteria to Clinical Indications for removal, revision, or replacement of a gastric electrical stimulator

Medical Policies

On November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect June 15, 2024.

Publish date

Medical Policy number

Medical Policy title

New or revised

1/3/2024

LAB.00026

Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer

Previously titled: Systems Pathology Testing for Prostate Cancer

Revised

1/3/2024

LAB.00046

Testing for Biochemical Markers for Alzheimer’s Disease

Revised

1/3/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

Conversion New

1/3/2024

MED.00057

MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

Revised

1/18/2024

*MED.00146

Gene Therapy for Sickle Cell Disease

New

1/3/2024

*RAD.00068

Myocardial Strain Imaging

New

1/3/2024

SURG.00010

Treatments for Urinary Incontinence

Revised

12/28/2023

*SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

Revised

12/28/2023

*SURG.00097

Scoliosis Surgery

Revised

1/3/2024

*SURG.00142

Genicular Procedures for Treatment of Knee Pain

Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain

Revised

1/3/2024

TRANS.00027

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

Revised

Clinical UM Guidelines

On November 9, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members on January 4, 2024. These guidelines take effect June 15, 2024.

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

1/3/2024

*CG-DME-42

Continuous Glucose Monitoring Devices

Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps

Revised

1/3/2024

CG-DME-44

Electric Tumor Treatment Field (TTF)

Revised

1/3/2024

CG-DME-50

Automated Insulin Delivery Systems

Conversion New

1/3/2024

CG-DME-51

External Insulin Pumps

Conversion New

1/3/2024

*CG-DME-52

Continuous Passive Motion Devices in the Home Setting

New

1/3/2024

CG-LAB-25

Outpatient Glycated Hemoglobin and Protein Testing

Revised

1/3/2024

CG-MED-92

Foot Care Services

Revised

1/3/2024

*CG-MED-94

Vestibular Function Testing

New

1/3/2024

*CG-SURG-09

Temporomandibular Disorders

Revised

12/28/2023

*CG-SURG-70

Gastric Electrical Stimulation

Revised

1/3/2024

CG-SURG-94

Keratoprosthesis

Revised

12/28/2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention

Revised

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CD-056961-24-CPN56516

Medical Policy & Clinical GuidelinesCommercialMay 28, 2024

Updates to Carelon Post-Acute Care Clinical Appropriateness Guidelines

Effective for dates of service on and after September 1, 2024, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management, Inc. guideline annual review process, these updates focus on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates

All post-acute care (PAC) guidelines — skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term acute care hospital (LTACH):

  • Re-structured original guidelines into three separate, level of care-specific guidelines
  • Updated background and definitions and refined several criteria to be more applicable to each guideline after re-structuring
  • Removed most criteria pertaining to transfer between other levels of PAC
  • Removed facility accessibility and health-related social needs (HRSN) criteria
  • Removed requirement for physician referral
  • Added sub-criteria to existing criteria in ongoing care regarding remaining therapeutic goals
  • Added verbiage and examples for clarification of original intent or for more level of care-specific applicability

LTACH only:

  • Refined criteria around need for hospice/palliative care consultation

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon Medical Benefits Management will begin receiving requests on May 29, 2024, for members whose anticipated discharge date is June 1, 2024, or after.

Providers are encouraged to request authorization using NexLync. Go to the Carelon Medical Benefits Management website to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.

To learn more about Carelon Medical Benefits Management and upcoming training webinars, visit https://providers.carelonmedicalbenefitsmanagement.com/postacute or email PACprovider_relations@carelon.com.

If you are unable to access/use any of the links or have other questions, call the Carelon Medical Benefits Management Provider Call Center at 833-431-0780 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-058856-24

Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageMay 3, 2024

Carelon Medical Benefits Management, Inc. genetic testing code updates

Effective for dates of service on and after September 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.:

CPT® code

Description

81457

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability

81458

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability

81459

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

81462

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (for example, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements

81463

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (for example, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability

81464

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (for example, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

0420U

Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma

0422U

Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate

0423U

Psychiatry (for example, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition

0424U

Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancer

0425U

Genome (for example, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (for example, parents, siblings)

0426U

Genome (for example, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis

0428U

Oncology (breast), targeted hybrid-capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden

0434U

Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes

0438U

Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

  • Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com.
    • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
  • Access Carelon Medical Benefits Management via the Availity website at Availity.com.

If you have questions related to guidelines, contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CRCM-056853-24-CPN56791

Prior AuthorizationCommercialJune 1, 2024

Expansion of Carelon Medical Benefits Management, Inc. programs

Effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The continued migration will expand clinical appropriateness review for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, radiation oncology, radiology, sleep, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — Additional outpatient UM (utilization management) that will include some transportation (including ambulance) and fertility procedures as set forth below. Transportation may include emergency post-service reviews.

The Clinical UM Guidelines and Medical Policies adopted by Anthem for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 23, 2024, for dates of service on or after October 1, 2024.

Members included in the new program

Updates to Carelon Medical Benefits Management programs apply to select local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplemental, or Federal Employee Program® (FEP®). For more information, please contact the phone number on the back of the member ID card.

Pre-service review requirements

For procedures that are scheduled to begin on or after October 1, 2024, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including, but not limited to, the following non-emergency modalities. Please refer to the Clinical Guidelines at anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.

Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.

Program

Services

Medical Policies or Clinical Guidelines

Additional Outpatient Utilization Management

  • Fertility
  • Therapeutic Apharesis
  • Hyperbaric Oxygen Therapy
  • Physiologic Record of Tremor
  • Home Parenteral Nutrition
  • Imaging Evaluation. of Skin Lesions
  • Ambulance Services (not applicable to Connecticut)
  • Virtual Reality-Assisted Therapy Systems
  • Quantitative Sensory Testing
  • Automated Nerve Conduction Testing
  • Bioimpedance Spectroscopy
  • Autonomic Testing
  • Continuous Monitoring of Intraocular Pressure
  • Seizure Monitoring
  • Electronic Home Visual Field Monitoring
  • Eye Movement Analysis for Diagnosis of Concussion
  • High-volume Colonic Irrigation
  • Electrical Stimulation as a Treatment for Pain and Other Conditions
  • Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
  • Automated Evacuation of Meibomian Gland
  • Selected Sleep Testing
  • CG-ANC-04
  • CG-ANC-06
  • CG-MED-66
  • CG-MED-68
  • CG-MED-73
  • CG-MED-88
  • CG-MED-89
  • CG-SURG-35
  • DME.00048
  • LAB.00045
  • MED.00004
  • MED.00082
  • MED.00092
  • MED.00101
  • MED.00103
  • MED.00105
  • MED.00112
  • MED.00118
  • MED.00130
  • MED.00131
  • MED.00137
  • MED.00141
  • DME.00011
  • MED.00011
  • MED.00002

Cardiovascular

  • Intracardiac Ischemia Monitoring
  • Outpatient Cardiac Hemodynamic Monitoring w/Wireless Sensor for Heart Failure Management
  • Non-invasive Heart Failure and Arrhythmia Monitoring System
  • Carotid Sinus Baroreceptor Stimulation Devices
  • Venous Angioplasty w/wo stent placement
  • VeinEembolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
  • Treatment of Varicose Veins (Lower Extremity)
  • Artery Stent Placement w/wo Angioplasty
  • Select Embolization procedures
  • Evaluation and Intervention for Dialysis Circuit Dysfunction
  • MED.00111
  • MED.00115
  • MED.00134
  • SURG.00124
  • SURG.00062
  • CG-SURG-106
  • CG-SURG-28
  • CG-SURG-76
  • CG-SURG-83
  • CG-SURG-93
  • CG-SURG-119
  • RAD.00059

Musculoskeletal

  • Ultrasound Bone Growth Stimulation.
  • Manipulation Under Anesthesia
  • Anesthesia for Interventional Pain Procedures.
  • Facet Joint Allograft Implants for Facet Disease
  • Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
  • Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
  • Extracorporeal Shock Wave Therapy
  • Implant of Nerve Stimulation Devices
  • Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
  • CG-MED-78
  • SURG.00114
  • SURG.00158
  • CG-DME-45
  • SURG.00112
  • CG-MED-65
  • CG-SURG-08
  • CG-SURG-89
  • SURG.00043
  • SURG.00045
  • SURG.00140
  • SURG.00144

Radiology

  • Magnetic Source Imaging & Magnetoencephalography
  • Low-Frequency Ultrasound Therapy for Wound Mgmt
  • Dynamic Spinal Visualization (Including Digital Motion X-ray & Cineradiography/ Videofluoroscopy)
  • Cervical and Thoracic Discography
  • CG-MED-76
  • MED.00096
  • RAD.00034
  • RAD.00053

Radiation Oncology

  • Neutron Beam Radiotherapy
  • THER-RAD.00008

Sleep

  • Electronic Positional Devices for Tx of OSA
  • Neuromuscular Electrical Training for Tx of OSA
  • Surgical Tx for OSA
  • DME.00042
  • DME.00043
  • SURG.00129

Surgical

Surgical GI:

  • High Resolution Anoscopy Screening
  • Doppler-Guided Transanal Hemorrhoidal Dearterialization

Base Surgical:

  • Anesthesia for Dental Services.
  • Skin Related Cosmetic and Reconstructive Services
  • Balloon Dilation of Eustachian Tubes
  • Functional Endoscopic Sinus Surgery
  • Bronchial Thermoplasty
  • Balloon Sinus Ostial Dilation
  • Cochlear and Auditory Brainstem Implants
  • Implantable Hearing Aids
  • Surgical Treatment for Obstructive Sleep Apnea and Snoring
  • Drug-Eluting Devices to Maintain Sinus Ostial Patency
  • Minimally Invasive Treatment of Posterior Nasal Nerve for Rhinitis
  • MRI Guided High-intensity Focused Ultrasound Ablation for Non-Oncologic Indications
  • Uterine Fibroid Ablation
  • Sacral Nerve Stimulation as a reatment of Neurogenic Bladder secondary to Spinal Cord Injury
  • Vagus Nerve Stimulation
  • Ablation for Solid Tumors Outside the Liver
  • Irreversible Electroporation
  • Corneal Collagen Cross Linking
  • Intraocular Telescope
  • Automated Evacuation of Meibomian Gland
  • Presbyopia and Astigmatism-correcting Intraocular Lenses
  • Viscocanalostomy and Canaloplasty
  • Intraocular Anterior Segment Aqueous Drainage Devices
  • Implanted Artificial Iris Devices
  • Implanted Port Delivery Systems for Ocular Disease
  • Implantable Infusion Pumps
  • Treatments for Urinary and Fecal Incontinence, Urinary Retantion
  • Reduction Mammaplasty
  • Mastectomy for Gynecomastia
  • Panniculectomy and Abdominoplasty
  • Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation
  • Products for Wound Healing and Soft Tissue Grafting
  • Surgical and Ablative Treatments for Chronic Headaches
  • Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
  • Mandibular/Maxillary Surgery
  • Blepharoplasty, Repair and Brow Lift
  • Internal Rib Fixation Systems
  • Prostate Saturation Biopsy
  • Focal Laser Ablation for the Treatment of Prostate Cancer
  • Penile Prosthesis Implantation
  • Diaphragmatic/Phrenic Nerve Stimulation and Pacing Systems
  • High Intensity Focused Ultrasound Ablation for Oncologic Indications
  • Renal Sympathetic Nerve Ablation
  • Hysterectomy
  • Laparoscopic Gynecologic Surgery
  • Myomectomy
  • Transurethral Destruction, Prostate Tissue
  • Temporomandibular Disorders (SURG-09)
  • Septoplasty (SURG-18)
  • Bariatric Surgery and Other Treatment for Clinically Severe Obesity (SURG-81)
  • Nasal Valve Repair (SURG.00079)
  • Bone-Anchored and Bone Conduction Hearing Aids (SURG-82)

  • ANC.00007
  • CG-MED-41
  • CG-MED-79
  • CG-MED-81
  • CG-SURG-03
  • CG-SURG-08
  • CG-SURG-09
  • CG-SURG-105
  • CG-SURG-12
  • CG-SURG-117
  • CG-SURG-118
  • CG-SURG-120
  • CG-SURG-18
  • CG-SURG-24
  • CG-SURG-61
  • CG-SURG-71
  • CG-SURG-73
  • CG-SURG-79
  • CG-SURG-81
  • CG-SURG-82
  • CG-SURG-83
  • CG-SURG-84
  • CG-SURG-88
  • CG-SURG-95
  • CG-SURG-96
  • CG-SURG-99
  • MED.00057
  • MED.00103
  • MED.00132
  • SURG.00010
  • SURG.00011
  • SURG.00118
  • SURG.00061
  • SURG.00077
  • SURG.00079
  • SURG.00084
  • SURG.00095
  • SURG.00096
  • SURG.00107
  • SURG.00116
  • SURG.00120
  • SURG.00126
  • SURG.00129
  • SURG.00132
  • SURG.00135
  • SURG.00139
  • SURG.00141
  • SURG.00156
  • SURG.00157
  • SURG.00159
  • SURG.00160
  • MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal
  • MCG: ISC: S-450/450-RRG/5450: Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy
  • MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal
  • MCG: ISC: S-665/665-RRG: Hysterectomy, Laparoscopic
  • MCG: ISC: S-775/775-RRG: Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy

To determine if prior authorization is needed for a member on or after October 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on Availity.com to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providerportal.com to register.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:

Our website at anthem.com helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQs. You can also contact your local network relations representative if you have any questions.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

* For New York, notice subject to regulatory approval.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Carelon Insights, Inc. provides payment integrity services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-059094-24

Products & ProgramsMedicaidJune 1, 2024

Bringing whole person care to sickle cell disease management

Call to action

We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities. We are excited to share a new and improved way to care for people living with sickle cell disease (SCD). Anthem has created a comprehensive SCD care management program. The program partners with members and care providers to remove barriers to care, improve and facilitate treatment adherence, and increase the quality of life for people living with SCD. By focusing on the prevention of SCD complications and building strategies for effective pain management, we aim to reduce preventable emergency department (ED) utilization and hospital admissions.

Our goal is to ensure that members with SCD receive comprehensive whole person care that goes beyond treating disease symptoms. Through this program, we will provide disease education, medication adherence monitoring, care coordination, as well as connections to community resources that support social drivers of health and other critical services. By building trusting relationships between Anthem, our members, care providers, and community resources, we assist our members in achieving the best quality of life possible.

To refer a Medicaid-enrolled member to the SCD Care Coordination program, call Provider Services at 844-396-2330.

Why this is important

SCD is a chronic condition and is the most common inherited red blood cell disorder in the United States affecting at least 100,000 Americans1. The Center for Disease Control and Prevention (CDC) reports that SCD affects one out of every 365 Black and African American births and one out of every 16,300 Hispanic and Latinx births1.

Most care providers are familiar with the unpredictable symptoms and long-term morbidities that individuals affected by SCD experience, including pain and vaso-occlusive crises, depression, and fatigue. Repeated vaso-occlusion, infarction, and chronic hemolytic anemia lead to organ dysfunction. More than half of people living with SCD have some organ disease and at least 24% have damage affecting multiple organs2. Vaso-occlusive events can have devastating consequences across all age groups. For example, it is estimated that 50% of people with SCD will experience cerebral vasculopathy by age 14 and 25% of adults with SCD will experience a stroke by age 45.2

Care providers might lose sight of the high medical costs (estimated to be over $1 million per individual lifetime6,1), barriers to care, and reduced quality of life people with SCD face. Despite medical advances in treatments, such as medications and gene therapy, large discrepancies in both outcomes and mortality rates for people with SCD still remain. One startling national statistic shows that life expectancy for people with SCD is at least 22 years lower than that for people without SCD6. These gaps can be attributed to multiple factors including limited access to comprehensive care.

The effects of SCD on quality of life are often unrecognized. Patients with SCD are more likely than people without SCD to have lost workdays and missed school days because of time spent in the hospital or ED6. The prevalence of depression and anxiety among people with SCD is five times greater than that of the general population.2

Patient experience is linked to their perceptions of quality of care.10 Many people living with SCD report dissatisfaction with the quality of care they receive. Contributing factors to this dissatisfaction include perceptions of racial discrimination, feelings of being stereotyped as drug seekers who do not have legitimate pain, barriers to accessing specialty care, and lack of clinician comfort with disease management — especially pain.10

The presence of implicit racial bias in healthcare and perceptions of discrimination are directly linked to negative health experiences.2 One example comes from a published study that showed people with sickle cell crisis in the ED waited 50% longer for pain treatment than patients who arrived with long bone fractures.3 In another study of ED wait times, patients with SCD waited an average of two hours longer for initial pain treatment compared to patients without SCD.3

Negative healthcare experiences lead to feelings of mistrust, which result in poor health outcomes. Patients with SCD who report experiences of discrimination are 53% more likely to report nonadherence to physician treatment recommendations.10 The lack of trusting relationships with healthcare providers correlates to low patient self-efficacy. This is compounded by obstacles related to social drivers of health which disproportionately affect many individuals living with SCD.

We designed this program in our pursuit to deliver the most comprehensive care and we believe it can foster close collaboration between Anthem and healthcare providers. This joint effort has the potential to address and eliminate the challenges our members with sickle cell disease currently face.

To support this endeavor, Anthem is ready to provide essential tools and resources needed to make a positive impact. Our shared commitment can help enhance the healthcare journey for our members.

References

  1. American Society of Hematology. (2022). The cost of living with sickle cell disease. tinyurl.com/2ezzzwzt.
  2. BlueBirdBio. (n.d.). We can change SCD. changeforscd.com
  3. Hutchinson S. (2023). For people with sickle cell disease, ERs can mean life-threatening waits. tinyurl.com/2fy2n5mb
  4. Jang T, Poplawska M, et al. (2021). Vaso-occlusive crisis in sickle cell disease: a vicious cycle of secondary events. Journal of Translational Medicine. 10.1186/s12967-021-03074-z
  5. Johnson KM, Boshen J, et al. (2023). Lifetime medical costs attributable to sickle cell disease among nonelderly individuals with commercial insurance. Blood Advances, 7(3). tinyurl.com/2phs7hcy
  6. Lubeck D, Agodoa I, Bhakta N, et al. (2019) Estimated life expectancy and income of patients with sickle cell disease compared with those without sickle cell disease. JAMA Network Open. tinyurl.com/5n8wyfrw
  7. Mainous AG, Tanner RJ, et al. (2015) Attitudes toward management of sickle cell disease and its complications: A national survey of academic family physicians. Anemia. Article ID 853835. tinyurl.com/2s5nwax9
  8. National Institutes of Health. (2022). Researchers identify the high costs of living with sickle cell disease. tinyurl.com/3mw6spxc
  9. Onimoe G, Rotz S. (2020) Sickle cell disease: a primary care update. 87(1) 19-27 ccjm.org/content/87/1/19
  10. Oyedeji C, Strouse J. Improving the quality of care for adolescents and adults with sickle cell disease – it’s a long road. JAMA Network Open. 2020;3(5) tinyurl.com/4464y44y
  11. United States, Department of Health and Human Services, Centers for Disease Control and Prevention. (7 July 2023). Are family physicians comfortable treating people with sickle cell disease? Centers for Disease Control and Prevention. tinyurl.com/yhr4tyb7
  12. Wachnik, AA, Welch-Coltrane, JL, Adams, MC, et al. (2022) A standardized emergency department order set decreases admission rates and in-patient length of stay for adult patients with sickle cell disease. Pain Medicine. doi.org/10.1093/pm/pnac096

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PharmacyMedicare AdvantageJune 1, 2024

Addressing medication adherence gaps

Medications are the primary intervention in treating and preventing disease. For most conditions, medications need to be taken 80% or more of the time to see an improvement in clinical outcomes.

Forty to fifty percent of patients are non-adherent to their medications for chronic conditions, leading to 100,000 preventable deaths and $100 to $300 billion in preventable medical costs per year.*

How can we prevent and close adherence gaps?

Be aware of contributing factors that influence non-adherence:

  • Cognitive impairment
  • Fear of side effects
  • Too many medications
  • History of non-adherence
  • Lack of perceived benefit
  • Confusion
  • Transportation
  • Cost

Implement a standardized process to identify patients with non-adherence:

  • Ask about adherence at every appointment.
  • Incorporate patient questionnaires or patient interviews using open-ended questions into existing workflows.
  • Analyze non-adherence reporting or claims to identify patients.
  • Leverage your electronic health record to identify patients at risk for non-adherence.

Be proactive: Tailor the solution to the patient’s needs or concerns:

  • Simplify the medication regimen by considering once daily dosing.
  • Always educate patients on benefits and risks of taking or not taking their medications.
  • Leverage real-time prescription benefit to select lower cost and formulary medications during the electronic prescribing process.
  • Consider home delivery (mail) and 90-day supply to prevent refill gaps, avoid long waits at the pharmacy, and minimize transportation barriers.

Consider medication non-adherence first as a reason when a patient’s condition is not under control.

*Kleinsinger F. The Unmet Challenge of Medication Nonadherence. Perm J. 2018; 22:18-033. doi: 10.7812/TPP/18-033. PMID: 30005722; PMCID: PMC6045499.
Gooptu A, Taitel M, Laiteerapong N, Press VG. Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications. Healthcare (Basel). July 31, 2021; 9(8): 976. doi: https://doi.org/10.3390/healthcare9080976.
Brown M, Sinsky CA. Medication Adherence. Improve Patient Outcomes and Reduce Costs. American Medical Association Steps Forward. June 5, 2015. https://edhub.ama-assn.org/steps-forward/module/2702595. Accessed May 16, 2023.
Eight reasons patients don’t take their medications. American Medication Association. Feb 22, 2023. Accessed May 17, 2023.
https://ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications.
El Halabi J, Minteer W, Boehmer KR. Identifying and Managing Treatment Nonadherence. Medical Clinics of North America. 2022; 106(4): 615-626. doi: https://doi.org/10.1016/j.mcna.2022.02.003.
Kini V, Ho PM. Interventions to Improve Medication Adherence. JAMA. 2018; 320(23): 2461. doi: https://doi.org/10.1001/jama.2018.19271.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-058771-24-CPN58567

PharmacyMedicare AdvantageJune 1, 2024

Improving patient outcomes with statin therapy in diabetes

Cardiovascular disease is the leading cause of death among people with diabetes. 1 National guidelines continue to recommend statin therapy in all patients with diabetes between the ages of 40 and 75, regardless of low-density lipoprotein (LDL) level, to prevent development of cardiovascular disease:

  • Reducing LDL-C levels by ~39 mg/dL with statin therapy can reduce heart disease and stroke mortality by 13%, regardless of the baseline LDL cholesterol levels.1
  • Nearly 60% of statin-eligible patients were never offered statin therapy by their doctor.2 Moreover, 50% of adults in the United States who would benefit from statins are taking them.3
  • Up to 34% of patients never fill the initial statin prescription (primary non-adherence).4

Statin Use in Patients with Diabetes (SUPD) is a CMS-adopted quality Star measure:

  • The SUPD measure is defined as percent of Medicare Part D beneficiaries 40 to 75 years old who were dispensed at least two diabetes medication fills and received a statin medication fill during the measurement period.
  • When assessing patients for appropriateness of statin therapy, also evaluate for potential measure exclusions.

Exclusions for the SUPD measure include:

  • End stage renal disease.
  • Hospice.
  • Rhabdomyolysis or myopathy.
  • Pregnancy/lactation.
  • Cirrhosis.
  • Pre-diabetes.
  • Polycystic ovary syndrome.
  • Fertility medication.

    • Reassess patient every year to evaluate the appropriateness of acceptable exclusions.
    • Exclusions require a submitted code each calendar year.

Best practices in initiating and improving statin adherence:

  • Offer statin therapy to all patients ages 40 to 75 years old who have diabetes, regardless of LDL.
  • Guidelines recommend moderate or high intensity statin depending on additional risks.
  • Get patient buy-in: Ask patients what they know about statins. Address any fears or concerns and educate them on statin benefits:
    • Fear of and perceived side effects are the most common reasons for declining or discontinuing statin therapy.4
  • Once a statin has been prescribed, follow up with patients to assess adherence.
  • Be aware of best practices to evaluate patient reported muscle side effects and an implementation strategy for re-initiation.

View a video about statins here.

References:

  1. American Diabetes Association Professional Practice Committee. 10. Cardiovascular disease and risk management: Standards of Care in Diabetes—2024. Diabetes Care 2024;47(Suppl. 1):S179–S218
  2. Bradley CK, Wang TY, Li S, et al. PatientReported Reasons for Declining or Discontinuing Statin Therapy: Insights From the PALM Registry. Journal of the American Heart Association. 2019;8(7). doi: https://doi.org/10.1161/jaha.118.011765
  3. Wall HK, Ritchey MD, Gillespie C, Omura JD, Jamal A, George MG. Vital Signs: Prevalence of Key Cardiovascular Disease Risk Factors for Million Hearts 2022 — United States, 2011–2016. MMWR Morb Mortal Wkly Rep 2018;67:983–991. DOI: http://dx.doi.org/10.15585/mmwr.mm6735a4
  4. 2 Tarn DM, Barrientos M, Pletcher MJ, et al. Perceptions of Patients with Primary Nonadherence to Statin Medications. The Journal of the American Board of Family Medicine. 2021;34(1):123-131. doi: https://doi.org/10.3122/jabfm.2021.01.200262
  5. CDC. Statins and Diabetes: What You Should Know. Centers for Disease Control and Prevention. Published January 30, 2023. cdc.gov/diabetes/library/features/Statins_Diabetes.html
  6. Kearney PM, Blackwell L, Collins R, et al.; Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008; 371:117–125
  7. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11). doi: https://doi.org/10.1161/cir.0000000000000678
  8. Collins R, Reith C, Emberson J, et al. The Lancet. 2016;388(10059):2532-2561. Interpretation of the evidence for the efficacy and safety of statin therapy. doi: https://doi.org/10.1016/s0140-6736(16)31357-5
  9. Hla D, Jones R, Blumenthal RS, et al. Assessing severity of statin side effects: Fact vs fiction. American College of Cardiology. April 09, 2018. Accessed May 17, 2023. acc.org/latest-in-cardiology/articles/2018/04/09/13/25/assessing-severity-of-statin-side-effects
  10. Reston JT, Buelt A, Donahue MP, Neubauer B, Vagichev E, McShea K. Interventions to Improve Statin Tolerance and Adherence in Patients at Risk for Cardiovascular Disease. Annals of Internal Medicine. 2020;173(10):806-812. doi: https://doi.org/10.7326/m20-4680

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PharmacyCommercialJune 1, 2024

Pharmacy information available on our provider website

Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about:

  • Copayment/coinsurance requirements and their applicable drug classes.
  • Drug lists and changes.
  • Prior authorization criteria.
  • Procedures for generic substitution.
  • Therapeutic interchange.
  • Step therapy or other management methods subject to prescribing decisions.
  • Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-058761-24-CPN58712

Quality ManagementCommercialApril 19, 2024

Improving patient health and digital literacies

Taking the time to help your patients boost their health and digital literacies can enhance trust and can lead to improved health outcomes and patient experience.

Refer to attachment to view full details

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-054705-24-CPN54222

ATTACHMENTS (available on web): Improving patient health and digital literacies (pdf - 0.47mb)

Quality ManagementCommercialMedicaidMay 15, 2024

Tips to Improve Adolescent Immunization (IMA) Rates

Vaccines are important in reducing the incidence of morbidity and mortality due to serious preventable diseases. Except for the annual flu and COVID vaccines, most childhood vaccines are administered before six years of age. Once children enter their pre-teen years, it is time for them to get a few more vaccines. The Center for Disease Control (CDC) and the American Academy of Pediatrics recommend pre-teens 11 and 12 years old get three vaccines to prevent diseases: 1) tetanus, diphtheria, and pertussis (Tdap); 2) meningococcal disease; and, 3) cancers caused by the human papillomavirus (HPV).

Refer to attachment to view full details

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

1 Nandi, Arindam and Anita Shet. “Why vaccines matter: understanding the broader health, economic, and child development benefits of routine vaccination.” Human Vaccines and Immunotherapeutics. 220; 16(8): 1900-1904. tinyurl.com/3wshrt62.
2 Reference: Ventola, C. Lee. “Immunization in the United States: Recommendations, Barriers, and Measures to Improve Compliance.” Pharmacy and Therapeutics. 2016 Jul; 41(7): 426-436. tinyurl.com/4m7s2tcc 1/30/2024.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CDCM-059583-24-CPN50915

ATTACHMENTS (available on web): Tips to Improve Adolescent Immunization (IMA) Rates (pdf - 0.23mb)

Quality ManagementCommercialMedicare AdvantageApril 22, 2024

Statin Use in Persons with Cardiovascular Disease (SPC) measure exclusion criteria: HEDIS® 2024 measurement year

Measure details

Eligibility criteria:

Numerator

Males 21 to 75 years of age and females 40 to 75 years of age as of December 31, 2024, who were dispensed at least one high- or moderate-intensity statin medication during 2024.

Denominator

Males 21 to 75 years of age and females 40 to 75 years of age as of December 31, 2024, who have been diagnosed with clinical atherosclerotic cardiovascular disease (ASCVD) during 2024.

Did you know?

Certain adverse reactions to a statin medication may exclude the patient from the measure denominator if properly documented. See required exclusions below.

Required exclusions:

  • Diagnosis of myalgia, myositis, myopathy, or rhabdomyolysis during 2024:
    • Important note: The above exclusionary diagnoses must be documented each year. A diagnosis from a prior year will not carry over to the current year.  These exclusionary diagnoses can come from claims or medical record data.  Medical record documentation must contain two patient identifiers.
  • Diagnosis of pregnancy during 2024
  • Diagnosis of in-vitro fertilization in 2023 or 2024
  • Dispensed at least one prescription for clomiphene during 2023 or 2024
  • 66 years of age and older who are enrolled in an Institutional Special Needs Plan (I-SNP) or living long term in an institution during 2024
  • 66 years of age and older with advanced illness during 2023 and/or 2024 and frailty during 2024
  • 66 years of age and older with advanced illness during 2023 and/or 2024 and dispensed dementia medication during 2024:
    • Note: Exclusions for advanced illness, frailty, and dispensed dementia medications must come from claims.
    • The advanced illness exclusion can include telephone visits, e-visits, and virtual check-ins to meet the two visits with an advanced illness diagnosis criterion.
  • Diagnosis of end-stage renal disease (ESRD) or dialysis during 2023 or 2024
  • Diagnosis of cirrhosis during 2023 or 2024
  • Hospice and palliative care
    • Death

Closing the gap

Documentation needed:

  • Only dispensed medication on a pharmacy claim is used to identify and close this gap.
  • Patient must use their member ID card when filling a statin prescription at the pharmacy.
  • Exclusions for advanced illness, frailty, and dispensed dementia medications must come from claims.
  • Exclusions for myalgia, myositis, myopathy, or rhabdomyolysis can come from claims or medical record data. Medical record documentation must include two patient identifiers.

Moderate- to high-intensity statin medications

Description

Prescription

High-intensity statin therapy

Atorvastatin 40 to 80 mg

Amlodipine-atorvastatin 40 to 80 mg

Rosuvastatin 20 to 40 mg

Simvastatin 80 mg

Ezetimibe-simvastatin 80 mg

Moderate-intensity statin therapy

Atorvastatin 10 to 20 mg

Amlodipine-atorvastatin 10 to 20 mg

Rosuvastatin 5 to 10 mg

Simvastatin 20 to 40 mg

Ezetimibe-simvastatin 20 to 40 mg

Pravastatin 40 to 80 mg

Lovastatin 40 mg

Fluvastatin 40 to 80 mg

Pitavastatin 1 to 4 mg

Best practices

Prescribe low-cost generics to eliminate cost as a barrier:

  • Atorvastatin, lovastatin, pravastatin, simvastatin, and rosuvastatin are available for $0 for extended days’ supply prescriptions. These medications are free using the Medicare Advantage prescription drug plan benefit for Anthem even if the patient reaches the coverage gap.
  • Encourage patients to fill their statin medication at a preferred pharmacy using their benefit.
  • Discourage the use of discount cards.
  • Let Anthem know of any patients filling outside of the benefit. Anthem can reach out to the pharmacy and/or patient regarding the $0 benefit cost.
  • Short trial fills of a statin medication with $0 cost may help hesitant patients be more willing to try or re-try a statin medication.

Help patients manage potential side effects:

  • Educate patients about the long-term cardiovascular benefits and potential side effects of a statin medication.
  • If a patient experienced statin intolerance previously, a trial of a lower dose or different statin medication may help reduce risk or side effects.

Note: Patient history of statin-induced myalgia, myositis, myopathy, or rhabdomyolysis in a prior year must be documented each year for patient to be excluded from this measure. A diagnosis from a prior year will not carry over to the current year.

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

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CRCM-055731-24-CPN55314

Quality ManagementMedicaidJune 1, 2024

Complex Care Management program

Managing illness can be a daunting task for our members, your patients. It is not always easy to understand test results, how to obtain essential resources for treatment, or whom to contact with questions and concerns. Our Complex Care Management program offers assistance.

Our care managers are part of an interdisciplinary team of clinicians and other resource professionals there to support members, families, PCPs, and caregivers. We leverage the experience and expertise of our team to educate and empower our members by increasing self-management skills. We 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 Member Services 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 members and caregivers are better prepared and informed about healthcare decisions and goals.

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

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CD-055499-24-SRS55499

Quality ManagementCommercialMay 6, 2024

Enhance patient access to digital health resources

Use this guide to help your patients better understand and use online health resources.

The Anthem.com/Provider Portal and Provider News Quality Management page contains training opportunities, resources, updates, pharmacy and behavioral health information, forms, and policies, and Availity information for billing.

Refer to attachment to view full details

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-054707-24-CPN54223

ATTACHMENTS (available on web): Enhance patient access to digital health resources (pdf - 0.42mb)

Quality ManagementCommercialMedicaidMay 7, 2024

Take action to improve adolescent immunizations rates

Estimates suggest that around 35 million American adolescents fail to receive at least one recommended vaccine.* The CDC and the American Academy of Pediatrics advise pre-teens between 10 and 12 years old receive three vaccines: (1) one dose for meningococcal; (2) one dose for tetanus, diphtheria, and pertussis (Tdap); and (3) two doses of human papillomavirus (HPV) given five months apart.

Encourage pre-teen immunizations

Take action to provide clear and specific guidance to your patients’ parents to get the recommended vaccines on time. Convey the importance by administering vaccines as part of routine visits and by offering vaccine clinics during non-traditional times when your patients and their parents might be more available. It is helpful to remind patients of their upcoming appointments, follow up to reschedule any missed appointments, and address any concerns or barriers. Although you should check your patients’ benefits, immunizations are generally a covered benefit.

Reporting and documenting for HEDIS

Take action to make sure that all vaccine doses given, including those administered in a pharmacy and an urgent care, are clearly documented in your electronic medical system, your patient’s medical record, and state Immunization Registry. Doses should be clearly reported on claim forms with the assistance of CPT® codes to maximize data collection and to reduce the burden of HEDIS® medical record review, especially since NCQA strongly encourages the electronic collection of Immunizations for Adolescents (IMA) HEDIS data. Contact your provider relationship management representative for additional information and assistance with establishing electronic data exchange.

Opportunities to learn more:

  • An on-demand webinar about the importance of the HPV vaccine and starting the conversation early with parents of 9-year-olds can be found on the Clinical Quality Webinars Hub. One continuing education unit is provided upon completion.
  • Mydiversepatients.com includes free resources and courses that might help you with your diverse patient population.
  • Letsvaccinate.org provides ready-to-use resources and strategies to help your care team increase vaccination rates.

Through our shared health vision, we can affect real change.

Das, Jai K., et al. Systematic Review and Meta-Analysis of Interventions to Improve Access and Coverage of Adolescent Immunizations. Journal of Adolescent Health. 2016 Oct; 59 (4 Suppl): S40-S48. ncbi.nlm.nih.gov/pmc/articles/PMC5026683.

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

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CDCM-055421-24-CPN50907