The Centers for Medicare & Medicaid Services (CMS) routinely revises the average sales price (ASP) fee schedules for drug pricing. CMS has issued the first quarter fee schedule effective January 1, 2023. This fee schedule went into effect for Anthem Blue Cross and Blue Shield providers on February 1, 2023. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

We previously communicated that Carelon Medical Benefits Management, Inc.,* a separate company, would expand the Musculoskeletal Program to perform medical necessity review of the requested site of service for certain joint and interventional pain procedures beginning September 1, 2022. The expansion was delayed and will now be effective April 1, 2023, for Anthem Blue Cross and Blue Shield (Anthem) fully insured consumers, as further outlined below.

Carelon Medical Benefits Management, Inc. will continue to manage the Musculoskeletal Program and level of care review. The Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). Carelon Medical Benefits Management, Inc. will use the following Anthem clinical utilization management guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The clinical criteria to be used for these reviews can be found on the Anthem Provider website Clinical UM Guidelines page. Note, this does not apply to procedures performed on an emergent basis.

A subset of the Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT^® codes requiring prior authorization for the Musculoskeletal Site of Care Program is available on the musculoskeletal microsite. To determine if prior authorization is needed for an Anthem consumer on or after April 1, 2023, contact the Provider Services phone number on the back of the consumer’s ID card for benefit information. If providers use the interactive care reviewer (ICR) tool on the Availity Essentials* website to pre-certify an outpatient musculoskeletal procedure, ICR will produce a message referring the provider to Carelon Medical Benefits Management, Inc.

Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management, Inc.

Consumers included in the new program

This program will be available to fully insured members that currently participate in the Carelon Medical Benefits Management, Inc. Musculoskeletal Program that have added the Musculoskeletal Site of Care Program to their consumers’ benefit package as of April 1, 2023.

Consumers of the following products are excluded from this program:

• Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program^® (FEP)

Pre-service review requirements

For services provided on or after April 1, 2023, ordering and servicing providers may begin contacting Carelon Medical Benefits Management, Inc. as early as March 15, 2023, for review. Providers may submit prior authorization requests to Carelon Medical Benefits Management, Inc. in one of several ways:

• Access the ProviderPortal_SM 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, Inc. via the Availity Essentials website at availity.com.
• Call the Carelon Medical Benefits Management, Inc. Contact Center toll-free number at 877‑430-2288, Monday through Friday, 8 a.m. to 6 p.m. Eastern time.

Training webinars

Carelon Medical Benefits Management, Inc. will be offering two Musculoskeletal Site of Care Program training sessions that providers are invited to attend:

• Thursday, March 9, 2023 – 11 a.m. CT
• Wednesday, March 15, 2023 – 11 a.m. CT

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

Effective June 1, 2023, Anthem Blue Cross and Blue Shield (Anthem) is implementing a new policy related to submission of certain clinical data that builds upon our 2021 policy regarding sharing of ADT notifications.

When requested by Anthem, providers will be required to submit clinical data (such as discharge summaries, consult notes, and medication lists) and admission, discharge, and transfer (ADT) data to Anthem for certain healthcare operations functions. We collect this data to improve the quality and efficiency of healthcare delivery to our members. Providers are required to submit:

• ADT data to Anthem on a near real-time basis (no later than 24 hours) from the time of admission, discharge, or transfer of a member.
• Clinical data for a member on a daily, weekly, or monthly basis, based on the provider's electronic medical record (EMR) or other electronic data sharing capabilities.

Anthem’s permitted uses of the data with respect to clinical data requests include utilization management, case management, identification of gaps in care, conducting clinical quality improvement, risk adjustment, documentation in support of HEDIS^® and other regulatory and accrediting reporting requirements, and for any other purpose permitted under HIPAA.

Anthem has determined the data requested is the minimum necessary for Anthem to accomplish its intended purposes. The data will be provided in accordance with data layout and format requirements defined by Anthem.

We value you as our partner in providing quality care and appreciate your continued participation in our network.

We communicated in the June 2022 edition of the Provider News that Carelon Medical Benefits Management, Inc.* (then, AIM Specialty Health_®), would expand the Musculoskeletal Program for Anthem Blue Cross and Blue Shield (Anthem) fully insured members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon beginning October 1, 2022. However, the initial program implementation was delayed. The confirmed new implementation date is April 1, 2023.

Unless otherwise stated in the provider’s agreement, for services on or after April 1, 2023, prior authorization will be required for the clinical appropriateness of monitored anesthesia or conscious sedation (MAC) when requested in conjunction with interventional pain codes. Carelon will use the following Anthem Clinical UM Guideline: CG-MED-78: Anesthesia Services for Interventional Pain Management Procedures. The Clinical Criteria to be used for these reviews can be found on the Anthem provider website Clinical UM Guidelines page. Clinical site of care review may also apply if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center. If you have a member in a current course of treatment for pain management where services were approved without reviewing the MAC, identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.

The anesthesiologist may determine that a member requires monitored anesthesia on the day of service. A retrospective review may be requested, or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC, and a detailed description of the procedure performed for Carelon to determine coverage for the service as medically necessary.   

At this time, the codes that will be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. A complete list of CPT^® codes requiring prior authorization for the Carelon Monitored Anesthesia Care for Interventional Pain program is available on the Carelon Musculoskeletal microsite. To determine if prior authorization is needed for a member on or after April 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials* platform to pre-certify an outpatient musculoskeletal service will receive a message referring the provider to Carelon. (Note: ICR cannot accept prior authorization requests for services administered by Carelon.)

Members included in the new program

All fully insured members currently participating in the Carelon Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the Carelon Musculoskeletal Program to add to their members’ benefit package as of April 1, 2023.

Members of the following products are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program^® (FEP^®). 

Pre-service review requirements

For services provided on or after April 1, 2023, ordering and servicing providers may begin contacting Carelon as early as March 20, 2023, for review. Providers may submit prior authorization requests to Carelon in one of the following ways:

• Access Carelon’s ProviderPortal_SM directly at www.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. Initiating a request on Carelon’s ProviderPortal_SM and entering responses to all the requested clinical questions will allow you to receive an immediate determination.
• Access Carelon via Availity Essentials* at www.availity.com in Payer Spaces under the Resources tab.
• Call the Carelon Contact Center’s toll-free number at 877-291-0360, Monday through Friday, 8 a.m. to 5 p.m. ET.

Training webinars

Carelon will be offering two Monitored Anesthesia Care training sessions that providers are invited to attend:

• Thursday March 30, 2023 – 12 p.m. ET
  Register here.
• Thursday April 6, 2023 – 12 p.m. ET
  Register here.

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

Prefix reference list - Nevada

Register today for the Advancing Mental Health Equity for Youth & Young Adults forum hosted by Anthem and Motivo* for Anthem providers on March 15, 2023.

Anthem is committed to making healthcare simpler and reducing health disparities for youth and young adults. We believe that advancing health equity for young people is critical to not only improving their experience, but also ensuring the mental health system is a safe and trusted resource. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem as we discuss the intersection of mental health, race, sexual orientation, gender identity, disability, and supporting youth and young adults on their mental health journey.

Each quarterly forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase diversity equity and inclusion in healthcare.

Wednesday, March 15, 2023

4 to 5:30 p.m. ET 

Please register for this event by visiting this link.

Join us as a partner with the American Cancer Society’s Mission: HPV Cancer Free a public health initiative to drastically reduce HPV cancer by increasing HPV vaccination rates by starting HPV vaccinations at age 9.

The Statin Therapy Exclusions for Patients With Cardiovascular Disease (SPC) HEDIS^® measures examines the percentage of patients with atherosclerotic cardiovascular disease (SPC) who received and adhered to statin therapy throughout the measurement year. However, statin therapy does not work for everyone, and alternative therapies are necessary to minimize their risk for future complications. If you have patients who cannot tolerate statin therapy, it is important that you document and notify us annually so we can exclude the patients from your list of open care gaps. Refer to NCQA guidelines for a complete listing of exclusion criteria.

How to submit exclusion data:

• Indicate the appropriate ICD-10 code for encounters.
• Use standard data file submission or EMR/EHR access for supplemental data collection.

Exclusions are applied based on diagnosis codes on the date of service provided on the claim or through supplemental data collection. Based on the timing of your data submission and when reports are generated, it may take several weeks for exclusions to be reflected on your reports.

Please note, if exclusions are not coded properly or given to Anthem Blue Cross and Blue Shield in the proper format, the care gap will remain open until the failure reason is corrected. Patients listed on the open care gap report are assumed to tolerate statin therapy and will have their care gaps closed after claims for moderate to high intensity statins are adjudicated by Anthem.

Tips for implementing best practices and improving your quality scores:

• Educate your patients on the importance of adhering to their statin therapy regime and on potential side effects. If they start to experience muscle pain or weakness, have them contact you to discuss their options.
• Statin therapy should also be accompanied by lifestyle modifications, such as a healthy diet and exercise. Work with your patients to proactively identify and overcome any barriers that may prevent lifestyle modifications. Discuss creating a realistic, individualized exercise routine based on the patient’s ability and interests. Encourage a healthy diet based on the patient’s culture and locally available produce, stores, and resources.

If you have any questions or concerns about Anthem Blue Cross and Blue Shield you can contact the phone number on the back of the member’s ID card for Provider Services.

In conjunction with National Colorectal Cancer Awareness Month¹, Anthem Blue Cross and Blue Shield (Anthem) would like to remind healthcare professionals to raise awareness among their patients about the importance of colorectal cancer screenings.

Encourage your patients to make time for regular colorectal cancer screenings. It’s one of the most valuable ways they can protect their health. Colorectal cancer is the third most common type of cancer among adults². The good news for patients is the survival rate for colorectal cancer is about 90%³. Through screenings, colorectal cancer can be caught early, when it is more treatable. Regular screenings are ideal for early detection.  

The American Cancer Society⁴ recommends that most adults have regular colorectal cancer screenings from age 45 to age 75. Talking to your patients about when and how often they should be tested and what kind of screening is right for them is important to their good health.

You and your Anthem patients have access to high-quality, low-cost colorectal cancer screening fecal immunochemical test (FIT) kits by Labcorp.* If you have specific questions, contact the lab directly:

• Labcorp: FIT test, 888-LABCORP (888-522-2677) or labcorp.com/cancer/colorectal/providers

To find Labcorp or other participating labs in your patient’s plan network, select Find Care from the Provider Resources menu at https://www.anthem.com.

¹ Colorectal Cancer Awareness Month | Colorectal Cancer Alliance

² Key Statistics for Colorectal Cancer https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html  

³ Survival Rates for Colorectal Cancer  https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/survival-rates.html

⁴ Colorectal Cancer Guideline | How Often to Have Screening Tests

Effective for dates of service on and after June 1, 2023, the following code updates will apply to the Carelon Medical Benefits Management, Inc. Radiology Clinical Appropriateness Guidelines.

Advanced imaging of the abdomen and pelvis

Oncologic imaging

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

• Access the ProviderPortal_SM 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 the the Availity* website at availity.com.

If you have questions related to guidelines, please email MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

The provider payment option, Pay Doctor Bill, offered to consumers via InstaMed,* will be terminated effective March 31, 2023. Anthem contracted with InstaMed to deliver options for consumers to view their claims and pay their out-of-pocket responsibility to doctors from the Sydney Health mobile app or from https://www.anthem.com/provider.This is not related to the payment of health insurance premiums.

Even though this option will no longer be available, consumers still have other ways of paying doctors:

• Through a Health Savings Account (HSA) or Flexible Spending Account (FSA) if they have this type of account
• Through their bank’s bill pay feature on a mobile app or website
• Directly through doctor’s secure payment website or at the doctor’s office with a debit or credit card

A month prior to the termination of Pay Doctor Bill from the Sydney Health mobile app and the Anthem website, we will notify consumers within these applications.

Medicaid

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

• Radiology update
• Prior authorization updates for medications billed under the medical benefit (Carvykti)
• Prior authorization updates for medications billed under the medical benefit (Aduhelm)

The Controlling High Blood Pressure (CBP) HEDIS^® measure can be challenging as it not only requires proof of a blood pressure (BP) reading, but also that the patient’s blood pressure is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 140/90 mmHG. As we start a new year, it’s important that we have record of your patients’ blood pressure readings and that you continue to monitor patients with elevated readings.

Tips when scheduling members to close CBP care gaps:

• When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
• If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time as well as a reminder to arrive early to avoid a sense of rushing.

Tips for lower BP readings during the appointment:

• Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their blood pressure at both the start and end of the appointment and document the lower reading.
• Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.

Getting credit for adequately controlled blood pressure readings:

• Submit readings via Category II CPT® codes on claims.
  

  Description	Code
  Diastolic BP	CAT II: 3078F-3080F LOINC: 8462-4
  Diastolic 80 to 89	CAT II: 3079F
  Diastolic greater than/equal to 90	CAT II: 3080F
  Diastolic less than 80	CAT II: 3078F
  Systolic BP	CAT II: 3074F, 3075F, 3077F LOINC: 8480-6
  Systolic greater than/equal to 140	CAT II: 3077F
  Systolic less than 140	CAT II: 3074F, 3075F

• Ensure readings are carefully and appropriately documented within your electronic medical record system.
• If you have questions on how to submit readings, speak to your care or practice consultant.
• Also, be sure to adequately code patients who meet the exclusion criteria:
  • Exclusions:
    • Palliative care
    • Enrolled in hospice
    • Frailty and/or advanced illness
    • Living in long-term care
  • Optional exclusions:
    • Dialysis (ESRD), kidney transplant, nephrectomy
    • Female members with a diagnosis of pregnancy
    • Non-acute inpatient admissions

(Policy G-06006)

The Modifier Usage policy is aligning with Medicare modifier requirements by adding the following to our Related Coding section:

• Modifier CO — Outpatient occupational therapy assistant services
• Modifier CQ — Outpatient physical therapy assistant services

Additionally, Modifier FB (Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples) was expanded to facility providers.

For additional information, please review the Modifier Usage reimbursement policy at https://www.anthem.com/medicareprovider.

Anthem Blue Cross and Blue Shield is actively seeking to promote CMS’s transition care management (TCM) program for its Medicare members.

The goal is to ensure comprehensive physician follow-up and management of patients within seven and/or 14 days of discharge from hospital, skilled nursing facility (SNF), inpatient rehabilitation hospital (IRF), or long-term acute care hospitals (LTAC). And thus, to minimize clinical relapses, that often result in acute hospital readmissions, within 30-days of discharge.

CPT^® codes for these visits are:

• 99496 (post-discharge comprehensive follow-up within seven days): pays between $250 to $350, depending on region, and;
• 99495 (post-discharge follow-up within 14 days): pays between $190 to $260, depending on region. 

The primary intent for these visits is close post-discharge patient follow up with comprehensive physician/provider management of ongoing chronic comorbidities. So, visits should include:

• Review of the discharge information
• Medication reconciliation
• Treatment of acute exacerbations and/or fluctuations in the physician office as appropriate
• Active management of and attention to chronic renal, lung, cardiac, skeletal, social, caregiver, etc. conditions, and providers should:
  • Review the need for pending diagnostics, and/or follow up of said diagnostics.
  • Interact with other healthcare professionals who may assume care of any system-specific problems.
  • Educate the patient, family, and caregiver.
  • Establish referrals, arrange needed community resources, address/assist/advise the member/family with relevant caregiver needs.
  • Help schedule required community providers and services follow-up.
  • Comprehensively and holistically manage common chronic/acute medical conditions seen after hospital discharge, such as (but not limited to): Heart failure, COPD, DM, AFIB, DVT, cellulitis, pneumonia, dehydration, AMS, encephalopathy, AKI, polypharmacy/medication reconciliation, and even custodial/social needs impacting/resulting in admission(s).

CMS encourages TCM for Medicare members. CMS has detailed fact sheets explaining the program, and billing, see resources below:

• https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf
• https://edit.cms.gov/files/document/billing-faqs-transitional-care-management-2016.pdf 

Appendix

CPT 99496 coding requirements:

1. Attestation that the initial communication between patient/practitioner began within two business days of discharge:
   1. Geared to patients with conditions requiring medium or high-level decision-making
   2. Direct contact: telephone/electronic
2. Face-to-face visit within seven days of DC. Cannot be virtual
3. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
4. Includes DC from hospitals, SNFs, IRFs, and LTACs
5. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living
   
   CPT 99495 coding requirements:
6. Attestation that the initial communication between patient/practitioner began within two business days of DC:
   1. Geared to patients with conditions requiring at least moderate complexity decision-making
   2. Direct contact: telephone/electronic
7. Face-to-face visit within 14 days of discharge. Cannot be virtual
8. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
9. Includes DC from hospitals, SNFs, IRFs, and LTACs
10. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living

An annual planned visit (APV) can be a significant driver of positive health outcomes and engagement with a patient’s provider. There are three main types of important, but often underutilized, APVs: initial preventive physical exam (IPPE), annual wellness visit (AWV), and annual routine physical (ARP). By engaging your patient early in the year to schedule these visits, there is opportunity to increase your APVs in 2023, and, in turn, improve the health of your patients and increase your success in the value-based programs (VBPs) you may participate in.

The AWV is an important opportunity to address up to 20 Medicare Advantage Stars measures that encompass both clinical quality and patient experience. The development of a personalized prevention plan is a required component of the AWV and can be a useful tool in leading these conversations with patients.

(AMJC).

The terms AWV and ARP are often incorrectly used interchangeably, which can cause confusion as these services are vastly different. AWVs are visits that are focused on preventive care, screenings, and the development of a personalized prevention plan. While an AWV includes taking standard measurements such as blood pressure, height, and weight, no hands-on physical exam is performed. The ARP is more extensive than an AWV in that it consists of a comprehensive, multi-system physical exam and includes bloodwork and other lab tests that are all based on the patient’s age, gender, and identified risk factors.

Note: An AWV and ARP may be performed during the same visit and providers can submit one claim that includes codes for both.



While the AWV may seem to have many requirements, several components of this visit can be performed by care team members other than the provider. See the sample workflow below that highlights steps that office staff can complete.

It is essential for providers to complete an APV for each of their assigned Medicare members. These visits help keep patients healthy and can increase practice revenue. For more tools and resources, please visit https://www.anthem.com/provider/medicare-advantage/ or reach out to your provider representative.

Medicare Advantage

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

• What date to select for inpatient admissions for claims
• Clinical Criteria updates
• New specialty pharmacy medical step therapy requirements