June 1, 2025

June 2025 Provider Newsletter

Featured Articles

Education & TrainingMedicare AdvantageMay 27, 2025

Learn about annual Model of Care training for special needs plans

Education & TrainingMedicaidMay 22, 2025

Provider manual updates for Nevada Medicaid

Education & TrainingCommercialMedicare AdvantageMedicaidMay 27, 2025

Boost your roster submission skills with Availity Essentials

Education & TrainingCommercialJune 1, 2025

Availity Essentials Provider Overpayments application launch


Administrative

AdministrativeCommercialMedicare AdvantageJune 1, 2025

LabCorp and Quest Diagnostics are in-network — reminder

Digital SolutionsCommercialMedicare AdvantageMedicaidMarch 1, 2025

Reminder: provider data attestation

Digital SolutionsCommercialMedicare AdvantageMedicaidJune 1, 2025

Submitting BH authorizations in Availity Essentials

Education & Training

Education & TrainingMedicare AdvantageMay 27, 2025

Learn about annual Model of Care training for special needs plans

Education & TrainingMedicaidMay 22, 2025

Provider manual updates for Nevada Medicaid

Education & TrainingMedicaidMay 13, 2025

You are invited: Medicaid provider orientation

Education & TrainingMedicare AdvantageJune 1, 2025

Bridging the gap: enhancing medication adherence for better health outcomes

Education & TrainingMedicare AdvantageJune 1, 2025

Claims guidance: updating inpatient and outpatient bill types

Education & TrainingCommercialMedicare AdvantageMedicaidMay 27, 2025

Boost your roster submission skills with Availity Essentials

Education & TrainingCommercialJune 1, 2025

Availity Essentials Provider Overpayments application launch

WebinarsCommercialMedicare AdvantageMedicaidJune 1, 2025

Registration is now available for our upcoming CME webinar on Integrating Cancer Care

Policy Updates

Policy UpdatesMedicaidApril 25, 2025

Carelon Medical Benefits Management, Inc. updates

Policy UpdatesMedicare AdvantageMay 13, 2025

Clinical Criteria updates

Policy UpdatesMedicaidMay 14, 2025

Carelon Medical Benefits Management, Inc. updates

Medical Policy & Clinical GuidelinesCommercialJune 1, 2025

Medical Policies and Clinical Utilization Management Guidelines are now available

Quality Management

Quality ManagementMedicaidJune 1, 2025

Enhance patient care with our Complex Care Management program

NVBCBS-CDCRCM-083881-25-CPN83757

AdministrativeCommercialMedicare AdvantageJune 1, 2025

LabCorp and Quest Diagnostics are in-network — reminder

Care providers have the opportunity to initiate member screenings and lab work without delay. To help detect and manage health conditions in a timely manner, set a proactive course for member wellness throughout the year. Early and routine screenings align with our commitment to comprehensive, preventive healthcare, contributing to better health outcomes for all.

Broader access for members and more options for care providers

Both our preferred national labs, LabCorp and Quest Diagnostics, are in-network for our Commercial and Medicare plans. This expansion not only broadened the spectrum of diagnostic options available but also enhanced convenience for members through increased specimen draw locations.

Our expanded network benefits members and care providers through:

  • Increased convenient testing locations and appointment scheduling: online appointment scheduling, conveniently located patient service centers, and timely access to results
  • Expanded testing options, including specialty testing expertise: broad menu of routine and specialized tests, including molecular, genetic, and genomic testing
  • Streamlined workflow and enhanced efficiency: easy-to-use lab management services for ordering tests and supplies, scheduling a specimen pickup, and tracking order status

We encourage you to share this update with your patients and leverage the expanded network for efficient and effective care delivery.

We are committed to helping patients more easily access the care they need. You can find our participating laboratories — including LabCorp and Quest Diagnostics — in our online provider directory at Find Care.

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.

CPN84095, CABC-CRCM-084215-25, MULTI-BCBS-CRCM-084216-25

AdministrativeCommercialJune 1, 2025

Update to claims system for global surgical procedures for professional providers

To align with the Centers for Medicare & Medicaid Services (CMS) guidance, we are updating our claims editing system regarding claim submissions for global surgical procedures. This update will ensure that reimbursements are accurately processed for clearly distinct surgical procedures performed during the postoperative period, excluding re‑operations or complications from treatment. These changes will be effective for dates of service starting on July 1, 2025.

Updated reimbursement eligibility criteria for global surgical procedures

  • Claim lines will not be eligible for reimbursement when a 0-day, 10-day, or 90-day global surgical procedure is submitted during the postoperative period of a prior 10-day or 90-day procedure by the same provider for the same member unless it is a distinct procedure.
  • The logic reviews the diagnoses reported to the seventh digit.
    If the diagnoses are different, the claim line will be allowed; if the diagnoses are the same, the claim line will not be allowed.
  • Modifiers 58, 78, and 79 or site modifiers E1‑E4, F1‑F9, FA, T1‑T9, TA, LM, RI, LC, LD, RC, RT, and LT are appropriate to identify unrelated procedures.

Example

The provider reports procedure code 68761‑E2 and diagnosis code H04.123 with the date of service of January 10, 2025. If the same provider reports procedure code 68760‑E2 and diagnosis code H04.123 with a date of service of January 16, 2025, the claim line for January 16, 2025, will not be allowed since the same site modifier and diagnosis are present as the procedure 10 days prior.

How to Initiate a Claims Payment Dispute

If you believe a claim reimbursement decision should be reviewed, follow the claims payment dispute process outlined in your provider manual, which is available at https://www.anthem.com/provider/individual-commercial/reimbursement.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

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-079577-25

Digital SolutionsCommercialMedicare AdvantageMedicaidMarch 1, 2025

Reminder: provider data attestation

At a glance:

  • Care providers contracted with us need to verify and update their demographic data every 90 days using the provider data management (PDM) feature in Availity Essentials.
  • Updating and attesting data are critical for maintaining accurate service directories for members and noncompliance with these requirements can result in removal from the online provider directory.
  • Availity Essentials provides digital applications that enable users to monitor submitted demographic updates in real time, review the history of previously verified data, and manage multiple updates within one spreadsheet via the Upload Roster feature.

What are the requirements for the attestation of demographic data?

We require our contracted care provider partners to attest to their demographic data every 90 days. Maintaining your provider data is critical as it results in improved connection to members seeking care, supports the accuracy of claims processing, and allows for timely reimbursement, while aligning to a bold purpose of improving the health of humanity.

How do I update and attest to my data?

We require the use of the PDM capability available on Availity Essentials to update your provider or facility data. There are two options within Availity Essentials PDM that are available at no cost to care providers:

  • Multipayer platform, which includes Directory Verification and Core PDM: allows care providers to make required updates using Directory Verification and changes using Core PDM
  • Roster upload: allows care providers to submit multiple updates within one spreadsheet via the Upload Roster feature (The Upload Roster feature is currently only available and shared with the health plan.)

Both the multipayer platform and Roster Upload feature satisfy your 90‑day attestation requirement.

To attest to your provider data:

    1. Log in to https://Availity.com.
    2. Navigate to My Providers > Provider Data Management.
    3. Select the action menu next to the business whose information you want to verify.
    4. Select Verify Directory Listing.
    5. Review each set of data for accuracy.
    6. Once complete, select Submit Verified Profile.

Organizations with no changes since their last submission may see a Quick Verify button that allows for directory verification in one click.

Individuals registered for their TIN within the Availity Manage My Organization application on Availity Essentials will receive periodic automated emails and notifications in the Notification Center on Availity Essentials reminding them when their attestation is due or overdue.

How do I access Availity Essentials and the PDM application?

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

Within PDM you also have the ability to:

  • Monitor submitted demographic updates in real time with a digital dashboard.
  • Review the history of previously verified data.

Why is updating and attesting to my data important?

Our members use Find Care to make informed decisions about their healthcare and find quality doctors and hospitals. Keeping your data up to date ensures members have access to you when they need it the most.

Failure to complete the 90‑day attestation requirement puts your organization at risk of being classified as non‑compliant with the health plan’s policies and procedures and may result in removal from the online provider directory.

What if I’m not registered for Availity Essentials yet?

If you aren’t registered to use Availity Essentials, signing up is easy and secure. There is no cost to register or to use any of the digital applications. Start by going to https://Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, 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 (282‑4548).

How do I get training on the Availity Essentials PDM tool?

You can learn about and attend one of our training opportunities by visiting here (apps.availity.com):

  • For more information on PDM, check out the Quick Start Guide here (apps.availity.com) using your Availity Essentials user ID and password.
  • For more information about the Roster Upload process:
    • See the Roster Submission Guide on https://Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using PDM.
    • Find training specifically for the Standard Template and Rules of Engagement by listening to our recorded webinar on our provider Learning Hub.
    • Take an on‑demand class hosted by Availity Essentials on the Learning Hub to learn about PDM.

What if I’m a behavioral health care provider?

If you are a behavioral health care provider and assigned to Carelon Behavioral Health, Inc., follow the Carelon Behavioral Health process for attestation. Council for Affordable Quality Healthcare (CAQH) care providers should attest, confirm, or update their data through the CAQH website. Non‑CAQH care providers and facilities should attest, confirm, or update their data directly with Carelon Behavioral Health.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

Carelon Health of New Jersey is an independent company providing utilization management services on behalf of the health plan.

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-078357-25-CPN78193, NVBCBS-CDCRCM-084121-25-CPN83900

Digital SolutionsCommercialMedicare AdvantageMedicaidJune 1, 2025

Submitting BH authorizations in Availity Essentials

By the end of the Summer 2025, you will be able to submit all your authorizations in one application on https://Availity.com.

You may already be submitting your physical health authorizations through the Availity Essentials multi‑payer Authorization application — taking advantage of the time savings and speed to care through digital authorization submissions. You will soon be able to submit both your physical health and behavioral health (BH) authorizations through one Authorization application on https://Availity.com.

Using the Authorization application to submit your BH authorizations will not be much different from the process you follow today. You may enjoy more intuitive screens or learn sooner if an authorization is required, but the digital submission process is still the best way to submit your authorization requests and the fastest way to care for our members.

You will continue to use Interactive Care Reviewer (ICR) to submit an appeal or authorization for medical specialty prescriptions.

Accessing the Authorization application is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, log on to https://Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals.

Training is available

Training is available for the Authorization application. Once registered with the authorization role assignment, visit the training site to enroll for an upcoming live webcast or to access an on‑demand recording at the Authorization Training Site.

We are focused on reducing administrative burdens, so you can do what you do best — care for 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-084280-25-CPN83622

Education & TrainingMedicare AdvantageMay 27, 2025

Learn about annual Model of Care training for special needs plans

In accordance with CMS guidelines, contracted Medicare Advantage care providers for special needs plans (SNP) must complete our annual Model of Care training. Providing a detailed overview of SNP, this training highlights cost sharing; data sharing; participation in the Interdisciplinary Care team; where to access the member’s health risk assessment results; plan of care and benefits coordination; and ensures the specific care needs of your patients, our members, are met.

To access the training, go to the link below:
https://www.anthem.com/content/dam/digital/docs/provider/commercial/ma/train/ABCBS-CR-070929-25.pdf

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-081455-25, CPN80849

Education & TrainingMedicaidMay 22, 2025

Provider manual updates for Nevada Medicaid

We have recently updated the provider manual for Nevada Medicaid, and we're excited to share these changes with you.

Our updated provider manual will be available for use and distribution as of July 1, 2025. You can obtain a copy by visiting https://providers.anthem.com/nv > Resources > Provider Manuals and Guides > Provider Manual.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our care provider website for the appropriate contact.

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-078095-25

Education & TrainingMedicaidMay 13, 2025

You are invited: Medicaid provider orientation

We are pleased to announce our monthly Medicaid care provider orientation webinar. You are cordially invited to attend this informative session.

The orientation aims to equip new care providers with insights into the system operations, guidelines, policies, and procedures of Medicaid services and refresh seasoned practitioners on the latest changes and enhancements.

Topics include:

  • Your responsibilities as a participating care provider
  • Member eligibility and benefits
  • Prior authorizations
  • Claims
  • Many more care provider resources

Register today!

To register, select one of the following dates:

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-082977-25

Education & TrainingMedicare AdvantageJune 1, 2025

Bridging the gap: enhancing medication adherence for better health outcomes

Did you know 40% to 50% of patients are non‑adherent to their medications for chronic conditions, leading to 100,000 preventable deaths and $100 to $300 billion in avoidable medical costs per year?

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.

Understanding the potential challenge

Medication adherence is not just about patients remembering to take their pills. Adherence is a multifaceted issue influenced by several factors, which can include:

  • Adherence challenges such as cognitive impairment, history of non‑adherence, and confusion or misunderstandings.
  • Concerns for the fear of side effects, perceived lack of benefit, and complex medication regimens.
  • Logistical or financial Issues such as transportation difficulties or high medication costs.

Implementing solutions

Identifying patients with adherence issues can be challenging. We recommend incorporating the following strategies into your practice:

  • Discuss adherence with patients at each appointment using open‑ended questions.
  • Analyze claims or non‑adherence reports to find at‑risk patients.
  • Use electronic health records for proactive identification of at‑risk patients.

Tailored and proactive approaches

Once identified, it is essential to tailor solutions to each patient’s unique needs:

  • Simplify regimens using once‑daily doses and 90‑day supplies with refills.
  • Educate patients by clearly explaining medication benefits and risks.
  • Streamline prescribing with real‑time prescription benefits.
  • Reduce pharmacy visits using e‑prescribe to CarelonRx for home delivery.

Spotlight on success

When patients struggle with controlling their condition, consider medication non‑adherence as a potential reason. Care providers can significantly improve patient outcomes and reduce healthcare costs by employing these strategies.


    References

    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-081808-25-CPN81335

    Education & TrainingMedicare AdvantageJune 1, 2025

    Claims guidance: updating inpatient and outpatient bill types

    Understanding how to update claims to bill inpatient and outpatient services accurately ensures prompt reimbursement, improves quality reporting, and increases patient satisfaction by mitigating unexpected costs. Please use the guidance below.

    Replacement of inpatient bill types

    When a claim is mistakenly billed as an inpatient bill type, it must be replaced using the ‘replacement bill type’ xx7. To correctly replace an inpatient bill type, the replacement must match the same bill type category:

    • Replace x11 with x17
    • Replace x31 with x37
    • Do not replace x11 with x37, or x17 with x31.

    Changing between inpatient and outpatient bill types

    To change billing from inpatient to outpatient or from outpatient to inpatient, follow these steps:

    1. Void the incorrect claim using ‘frequency type 8’ to avoid errors and overlaps.
    2. Create a new claim submission labeled ‘frequency type 1’ to represent the correct billing type.

    Contact your network manager or provider relationship management representative with any questions.

    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-082162-25-CPN81458

    Education & TrainingCommercialMedicare AdvantageMedicaidMay 27, 2025

    Boost your roster submission skills with Availity Essentials

    We are excited to announce two new interactive training courses for uploading rosters through the Availity platform. Dive into these two 20‑minute sessions and master the roster upload process with confidence.

    The Provider Roster Upload via Availity course will guide you through uploading rosters, troubleshooting errors, and downloading your data. The Roster Automation Standard Template course offers training on using a roster template to enhance compatibility and streamline the submission process.

    Don't miss this opportunity to unlock valuable insights. Visit https://Availity.com and navigate to Payer Spaces > Payer Tile > Resources to access the latest Roster Automation Standard Template and Roster Submission Guide.

    Access all training courses on the Digital Solutions Learning Hub.

    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.

    CPN80860, NVBCBS-CDCRCM-081937-25

    Education & TrainingCommercialJune 1, 2025

    Availity Essentials Provider Overpayments application launch

    This article was updated on June 27, 2025

    We are excited to announce the launch of the Availity Essentials Provider Overpayments application in July 2025. The Provider Overpayments application is a robust tool for improving digital communication in managing claim overpayments. It offers care providers a streamlined and efficient way to handle notifications, inquiries, disputes, and resolutions of overpayments directly through the Availity website.

    Benefits of the Availity Overpayments application:

    • Comprehensive management: Access a user‑friendly platform to help you efficiently oversee overpayment processes, from initiation to resolution.
    • Intuitive interface: Navigate easily through five overpayment statuses: Action Required, Inquired, Disputed, Resolved, and Closed, with overpayment details displayed as unique cards.
    • Enhanced communication: Benefit from integrated messaging functions and document uploads to facilitate clear communication and documentation.
    • Training and support: Training resources and support are available to assist you in maximizing the use of this tool. All application documentation/demos are available after logging into Availity Essentials.

    If you experience technical issues while logging in or using Essentials, contact Availity Client Services at 800‑AVAILITY for immediate assistance.

    The original Availity Essentials Overpayments Application training and demonstration schedule has been updated.

    Webinars, training resources, and support are available to help you maximize the use of this tool.

    For access to Availity Essentials learning resources, follow these two easy steps:

    1. Log in to Availity Essentials.
    2. Select the Help and Training menu.

    We look forward to helping you enhance operational efficiencies and improve claim overpayment management.

    Thank you for your continued partnership.

    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-080892-25

    WebinarsCommercialMedicare AdvantageMedicaidJune 1, 2025

    Registration is now available for our upcoming CME webinar on Integrating Cancer Care

    Please join us on June 10, 2025, for our upcoming CME webinar with Dr. Sarah Temkin from the American Cancer Society (ACS).

    Dr. Temkin will discuss current trends in breast and colorectal cancer incidence and mortality, the role of primary care in enhancing cancer outcomes, and the ACS's resources for optimal cancer care. The key measures that will be highlighted are Breast Cancer Screening and Colorectal Cancer Screening (ECDS).

    Register now by visiting this link:

    • Title: Integrating Cancer Care: Enhancing Prevention, Early Detection, and More in Primary Care
    • Date: Tuesday, June 10, 2025
    • Time: Noon ET

    This session is approved for one AAFP credit.
    The registration page opens best in the Google Chrome browser.

    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.

    CPN83044, CABC-CDCRCM-083183-25, NVBCBS-CDCRCM-083199-25, NYBCBS-CDCRCM-083200-25, OHBCBS-CDCRCM-083202-25, TXWP-CDCRCM-083204-25, VABCBS-CDCRCM-083205-25, WIBCBS-CDCRCM-083207-25

    Policy UpdatesMedicaidApril 25, 2025

    Carelon Medical Benefits Management, Inc. updates

    This article was updated on June 12, 2025.

    Effective on July 26, 2025, the following Carelon Medical Benefits Management Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

    The following guideline updates have a publish date of July 26, 2025:

    • Genetic Testing
      • Chromosomal Microarray Analysis
      • Pharmacogenomic Testing
      • Whole Exome Sequencing and Whole Genome Sequencing
    • Musculoskeletal
      • Interventional Pain Management

    You may access and download a copy of the current and upcoming guidelines here.

    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-080515-25-CPN80116, CPN-CD-086305-25-CPN86305

    Policy UpdatesMedicare AdvantageMay 13, 2025

    Clinical Criteria updates

    Effective June 20, 2025

    Summary: The Pharmacy and Therapeutics (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 our Clinical Criteria page to find specific policies. If you have questions or need additional information, please email us.

    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

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

    Note:

    • The Clinical Criteria listed below apply only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
    • This notice is meant to provide information on new or revised criteria that have 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

    Status

    June 20, 2025

    CC-0282

    Onapgo (apomorphine subcutaneous solution)

    New

    June 20, 2025

    CC-0149

    Select Clotting Agents for Bleeding Disorders

    Revised

    June 20, 2025

    CC-0037

    Kanuma (sebelipase alfa)

    Revised

    June 20, 2025

    CC-0159

    Scenesse (afamelanotide)

    Revised

    June 20, 2025

    CC-0245

    Izervay (avacincaptad pegol)

    Revised

    June 20, 2025

    CC-0197

    Jemperli (dostarlimab-gxly)

    Revised

    June 20, 2025

    CC-0106

    Erbitux (cetuximab)

    Revised

    June 20, 2025

    CC-0027

    Denosumab

    Revised

    June 20, 2025

    CC-0066

    Monoclonal Antibodies to Interleukin-6

    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-083392-25-CPN82744

    Policy UpdatesMedicaidMay 14, 2025

    Carelon Medical Benefits Management, Inc. updates

    Effective on June 20, 2025, the following Carelon Medical Benefits Management Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

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

    The following guideline updates have a publish date of March 23, 2025:

    • Genetic Testing:
      • Somatic Tumor Testing

    You may access and download a copy of the current and upcoming guidelines at https://guidelines.carelonmedicalbenefitsmanagement.com.

    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-081539-25-CPN80914

    Medical Policy & Clinical GuidelinesCommercialJune 1, 2025

    Medical Policies and Clinical Utilization Management Guidelines are now available

    Our new and revised Clinical Utilization Management (UM) Guidelines and Medical Guidelines, effective for service dates on and after September 1, 2025. Anthem will also implement changes to our Clinical UM Guidelines, which were adopted for Nevada. Anthem Medical Policies and Clinical UM Guidelines are developed by our national Medical Policy and Technology Assessment Committee (MPTAC). The MPTAC, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.

    The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

    New Clinical UM Guidelines and Medical Guidelines

    Policy or Guideline Number

    Policy or Guideline Title

    Explanation of Policy or Guideline

    CG-SURG-125

    Canaloplasty

    • Addresses canaloplasty, which is a form of non-penetrating glaucoma surgery. Canaloplasty is proposed as an alternative to trabeculectomy, the traditional surgical treatment of primary open-angle glaucoma (POAG).
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective September 1, 2025.

    DME.00053

    Home Video-Assisted Robotic Rehabilitation Systems

    • Addresses home use of video‑assisted robotic rehabilitation systems such as the Motus Hand or Motus Foot devices. The HCPCS code associated with this revised coverage guideline is E0739.
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective September 1, 2025.

    MED.00151

    Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency

    • Addresses gene therapy for aromatic l-amino acid decarboxylase (AADC) deficiency, which is a genetic disease involving variations in the human dopa decarboxylase (DDC) gene that reduce an individual’s ability to synthesize dopamine and serotonin from their precursor molecules. These chemicals are essential neurotransmitters that control many vital physiological functions such as sleep, memory, learning, brain development and cardiovascular function. A gene therapy product to treat AADC deficiency has been approved by the U.S. Food and Drug Administration (FDA), eladocagene exuparvovec-tneq (Kebilidi™). In Kebilidi therapy, an adeno-associated virus vector containing a functional copy of the human DDC gene is delivered directly into the brain through stereotactic injections. The viral vector infects the brain’s cells and causes a switch in the target genetic code, with the goal of allowing nerve cells to produce the missing enzyme.
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective September 1, 2025.

    MED.00152

    Outpatient Intravenous Insulin Therapy

    • Addresses outpatient intravenous insulin therapy, also referred to as the following:
      • Chronic intermittent intravenous insulin infusion therapy (CIIIT)
      • Hepatic activation
      • Metabolic activation therapy (MAT)
      • Outpatient intravenous insulin therapy (OIVIT)
      • Physiologic insulin resensitization (PIR)
      • Pulsatile intravenous insulin therapy (PIVIT)
      • Pulse insulin therapy (PIT)
    • Outpatient intravenous insulin therapy has been proposed as an adjunctive or alternative therapy for the treatment of type 1 diabetes.
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective September 1, 2025.

    SURG.00165

    Histotripsy

    • Addresses the use of histotripsy to ablate tissue. Histotripsy is an incisionless non-thermal procedure that uses ultrasound to induce mechanical cavitation resulting in the transformation of targeted tissue into acellular debris. The mechanism of action for histotripsy differs from that for high intensity focused ultrasound (HIFU). In HIFU, the heat produced by high intensity focused ultrasound directly destroys tissue. The spread of this heat can damage adjacent tissue. Histotripsy uses minimal heat to create microbubbles within tissue and it is these bubbles that destroy the tissue. Histotripsy has been proposed as a treatment for malignant tissue, including liver lesions and renal cancer. This treatment has also been proposed for treatment of nonmalignant conditions such as benign prostatic hypertrophy (BPH).
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective September 1, 2025.

    Revised Medical Policies and Clinical UM Guidelines

    Policy or Guideline Number

    Policy or Guideline Title

    Explanation of Revision

    CG-OR-PR-04

    Cranial Remodeling Bands and Helmets (Cranial Orthoses)

    Previously Titled: Cranial Remodeling Bands and Helmets (Cranial Orthotics)

    • Revised title.
    • Revised criterion regarding cervical motion restriction.
    • Revised Cranial Vault Asymmetry Index criteria.

    CG-THER-RAD-07

    Intravascular Coronary and Non-Coronary Brachytherapy

    Previously Titled: Intravascular Brachytherapy (Coronary and Non-Coronary)

    • Revised title.
    • Revised medically necessary and not medically necessary statements.

    DME.00011

    Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

    • Revised investigational and not medically necessary statement, adding bimodal (acoustic and peripheral nerve electrical stimulation) neuromodulation therapy.

    LAB.00026

    Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions

    • Added medically necessary criteria for ArteraAI Prostate cancer risk stratification test.
    • Revised investigational and not medically necessary statement to remove prostate cancer.

    LAB.00037

    Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

    • Revised investigational and not medically necessary statement to remove proprietary names and "for all other indications."

    TRANS.00029

    Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias

    • Removed age requirements for HSCT for aplastic anemia, SCD, and thalassemia from medically necessary criteria.

    TRANS.00033

    Heart Transplantation

    • Reformatted medically necessary statement.
    • Revised medically necessary CPET criteria.
    • Added medically necessary criteria related to history of malignancy.
    • Added Note regarding 2024 ISHLT listing guidelines.
    • Added new Pediatric medically necessary criteria related to PVR.
    • Revised Relative Contraindications for Transplant Recipients related to PVR.
    • Revised formatting in Absolute Contraindications for Transplant Recipients.

    Medical Policies and Clinical UM Guidelines archived effective January 30, 2025

    Policy or Guideline Number

    Policy Title

    Explanation of Archive Status

    CG-MED-42

    Maternity Ultrasound in the Outpatient Setting

    • Content moved to CG-RAD-26

    MED.00013

    Parenteral Antibiotics for the Treatment of Lyme Disease

    • Content moved to CG-MED-98

    MED.00097

    Neural Therapy

    N/A

    MED.00128

    Insulin Potentiation Therapy

    N/A

    SURG.00095

    Viscocanalostomy and Canaloplasty

    • Content for Viscocanalostomy moved to CG-SURG-124
    • Content for Canaloplasty moved to CG-SURG-125

    SURG.00116

    High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus

    N/A

    Medical Policies and Clinical UM Guidelines archived effective April 1, 2025

    Policy or Guideline Number

    Policy Title

    Explanation of Archive Status

    CG-MED-64

    Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins

    N/A

    CG-MED-74

    Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

    N/A

    CG-SURG-111

    Open Sacroiliac Joint Fusion

    N/A

    CG-SURG-55

    Cardiac Electrophysiological Studies (EPS) and Catheter Ablation

    N/A

    CG-SURG-93

    Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction

    N/A

    SURG.00152

    Wireless Left Ventricular Pacing for Cardiac Resynchronization Therapy

    N/A

    THER-RAD.00008

    Neutron Beam Radiotherapy

    N/A

    View the Medical Policies and Clinical UM Guidelines online

    The complete list of our Medical Policies and Clinical UM Guidelines may be accessed online. Enter the keyword or code or select Full List Page to search for the policy relevant to your inquiry.

    The Clinical UM guidelines published on the website represent the Clinical UM Guidelines currently available to all plans for adoption throughout our organization. Because local practice patterns, claims systems, and benefit designs vary, a local plan may choose whether or not to implement a particular Clinical UM Guideline. The link above can be used to confirm whether or not the local plan has adopted the Clinical UM Guideline(s) in question. Adoption lists are created and maintained solely by each local plan.

    All coverage written or administered by Anthem excludes from coverage services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medically necessary criteria set in Anthem medical policies. Review procedures have been refined to facilitate claim investigation.

    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-CM-083459-25

    PharmacyCommercialJune 1, 2025

    Unlock updated pharmacy insights today — visit our provider website

    We ask care providers to periodically review the pharmacy information available on our provider website for new or updated information. Staying updated on changes gives our members the best access to the highest quality care. Visit anthem.com/pharmacy-information for more information about:

    • Copay or coinsurance requirements and their applicable drug classes.
    • Drug lists and changes.
    • Preapproval criteria.
    • Procedures for generic substitution.
    • Therapeutic interchange.
    • Step therapy or other management methods subject to prescribing decisions.
    • Other requirements, restrictions, or limitations for 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.

    Visit carelonrx.com/solutions/providers for information on submitting a preapproval request or an exception request for a drug not on a drug list.

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

    If you do not have internet access, contact Provider Services via the number on the back of our member ID card to request a copy of the pharmaceutical information available online.

    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.

    CPN81432, MULTI-BCBS-CM-082674-25, CPN83672, MULTI-BCBS-CM-084709-25

    PharmacyMedicare AdvantageMay 22, 2025

    New specialty pharmacy medical step therapy requirements

    Starting July 1, 2025, the following Part B medications from the current Clinical Criteria Guidelines will be included in our medical step therapy precertification review process.

    Step therapy will apply to members upon precertification initiation in addition to the current medical necessity review.

    Step therapy will not apply to members actively receiving the medications listed below.

    Clinical Criteria Guidelines are publicly available at https://anthem.com/provider/medicare‑advantage. Visit the Clinical Criteria page to search for specific criteria.

    Clinical UM Guidelines

    Status

    Drug(s)

    CC-0072

    Preferred

    Pavblu (aflibercept-ayyh)

    CC-0072

    Non-preferred

    Ahzantive (aflibercept-mrbb)

    CC-0072

    Non-preferred

    Enzeevu (aflibercept-abzv)

    CC-0072

    Non-preferred

    Opuviz (afibercept-yszy)

    CC-0072

    Non-preferred

    Yesafili (aflibercept-jbvf)

    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-081303-25-CPN81191

    PharmacyMedicaidMay 15, 2025

    Prior authorization updates for medications billed under the medical benefit

    Effective for dates of service on or after July 1, 2025, the following medication codes will require prior authorization.

    Please note, inclusion of a national drug code (NDC) on the medical claim is necessary for claims processing.

    Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

    Clinical Criteria

    HCPCS or CPT® code(s)

    Drug name

    CC-0027

    Q5136

    Jubbonti; Wyost (denosumab-bbdz)

    CC-0269

    C9399, J3590

    Nemluvio (nemolizumab-ilto)

    CC-0002

    C9173, Q5148

    Nypozi (filgrastim‑txid)

    CC-0266

    J0870

    Rytelo (imetelstat)

    CC-0271

    Q2057

    Tecelra (afamitresgene autoleucel)

    CC-0003

    J3590

    Yimmugo (immuneglobulin intravenous, human‑dira)

    Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

    Contact us

    Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

    For additional support, visit the Contact Us section of our provider website for the appropriate contact.

    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-079918-25-CPN78812

    PharmacyMedicaidMay 20, 2025

    Prior authorization updates for medications billed under the medical benefit

    Effective for dates of service on or after July 1, 2025, the following medication codes will require prior authorization.

    Please note, inclusion of a national drug code (NDC) on the medical claim is necessary for claims processing.

    Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

    Clinical Criteria

    HCPCS or CPT® code(s)

    Drug name

    CC-0072

    Q5150

    Ahzantive (aflibercept‑mrbb)

    CC-0072

    Q5149

    Enzeevu (aflibercept‑abzv)

    CC-0072

    C9399, J3590

    Opuviz (aflibercept‑yszy)

    CC-0072

    Q5147

    Pavblu (aflibercept‑ayyh)

    CC-0072

    C9399, J3590

    Yesafili (aflibercept‑jbvf)

    Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

    Contact us

    Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

    For additional support, visit the Contact Us section of our provider website for the appropriate contact.

    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-079877-25-CPN78747

    Quality ManagementMedicaidJune 1, 2025

    Enhance patient care with our Complex Care Management program

    Managing illness can be daunting for our members — your patients. It can be difficult for them to understand test results, access essential resources for treatment, or know whom to contact with questions and concerns. Our Complex Care Management program offers assistance to members in need.

    Our care managers are part of an interdisciplinary team of clinicians and other resource professionals who support members, families, PCPs, and caregivers. We leverage our team’s experience and expertise to educate and improve our members’ self‑management skills. We help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare.

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

    For more information, please call contact Provider Services at 844‑396‑2330. Care Management’s business hours are Monday through Friday, 8 a.m. to 5 p.m. PT.

    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-080962-25-SRS80962