 Provider News NevadaMay 1, 2021 May 2021 Anthem Provider News - NevadaOften, healthcare costs incurred by Anthem Blue Cross and Blue Shield (Anthem) members are a result of recommendations made by their physicians. As an Anthem participating physician, you can help reduce your patients’ healthcare costs. Choices, such as where to refer a Member for Negative Pressure Wound Therapy, can have a significant impact on your patients’ ultimate out-of-pocket liability. We are sharing the following information with you for consideration when referring patients for Negative Pressure Wound Therapy.
Our Members, your patients, often participate in health benefit plans that may have coinsurance or deductibles. Your patients may experience significant differences in cost depending on which Negative Pressure Wound Therapy providers the Members are referred to. The following table provides a sample listing of Anthem high quality, low cost national Negative Pressure Wound Therapy providers. Referring to these providers will likely lower your patients’ out-of-pocket costs.
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Provider
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Phone Number
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Apria
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1-800-780-1228
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Rotech
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1-844-592-5068
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You can find all of Anthem’s participating durable medical equipment (DME) Orthotics and Prosthetics providers, at “Find Care” -- Anthem’s doctor finder and transparency tool – at www.anthem.com.
Anthem is committed to seeking ways to reduce healthcare costs, and your referrals to network- participating providers can help make a difference. We appreciate your partnership in considering the financial impact to your patients – our members – especially during these challenging economic times.
If you have questions, please contact your local Network Relations Consultant or call Provider Services.
All associates who make utilization management decisions are required to adhere to the following principles:
- Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
- We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support denials of benefits.
- Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization or create barriers to care and service.
Digital Online Scheduling Feature Now Available in the Availity Portal
The Appointment Scheduler application in Availity Payer Spaces is an online appointment-scheduling feature that allows providers to manage appointments with patients that may want to schedule appointments directly. Providers can manage patients’ appointment requests and maintain their appointment availability.
Providers can receive new appointment requests from active members, along with important information like the member’s ID number, contact information and any special health information they want the doctor to know. Providers can modify or deactivate their availability at any time. Availity Users with the role of “Office Staff” can set up physicians in the practice to accept online appointment requests.
Enrollment for Appointment Scheduler is easy. To access Appointment Scheduler in the Availity portal: Availity > Payer Spaces > Select Payer Tile > Applications
Appointment Scheduler Features:
- Manage appointment requests and view physician availability
- Configure appointment availability
- Notification of new visit requests on Availity Notification Center and via email
- Members are notified directly via text or email once appointment is confirmed
- Send patient reminders via the Appointment Scheduler application
- Customize office locations and available times, as well as the types of appointments accepted
Visit the Appointment Scheduler application in the Availity portal today.
We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well. The current health crisis illuminates this quite clearly. It is imperative to offer care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield (Anthem) is committed to supporting our providers in this effort.
MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:
- Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers to enhance care.
- Real life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.
While there is no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.
Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.
My Diverse Patients
Stronger Together Health Equity Resources
After receiving your feedback, we expanded our server to meet your need to upload larger files to our digital attachment tool, through Availity. You can now upload files up to 100 megabytes, eliminating the need to mail or fax.
Use the attachment tool to upload:
- Medical records
- Itemized bills
- Payment dispute
- EOB
- General correspondence
- Consent forms
The digital attachment tool file size expansion is just one example of how Anthem is using digital technology to improve the healthcare experience, with a goal to save you valuable time.
Access the attachment tool through www.Availity.com. From the Claims & Payments header, select Attachments – New. For more information about how to setup electronic attachments, use the Getting Started Guide: Select Help & Training>Find Help and then the Attachments topic in Contents. Once logged on you can also access the Getting Started Guide using this link.
For information about setting up for Program Integrity attachments, once logged on to Availity, use this link. You can also access Program Integrity attachment information from the Custom Learning Center: Payer Spaces>Custom Learning Center>Electronic Medical Records.
Our organization is working robustly to establish Anthem Blue Cross and Blue Shield (Anthem) as a digital-first enterprise and to streamline your daily working tasks by using electronic functionalities. In support of the Digital-First Solutions we are excited to publish two Provider Bulletins about submitting medical attachments and itemized bills in partnership with Availity.
The objective of the bulletins is to provide a simple guide for you and your staff with step-by-step navigation instructions, where to find help and training with medical attachments.
The provider bulletins are posted on the Custom Learning Center (CLC) under the Resources tab. Follow these steps to access the helpful documents:
- Availity > Payer Spaces > Select Payer Tile > Applications > Custom Learning Center
- Select Catalog > Resources to locate, view or download the Provider Bulletins
Please encourage your staff who have questions on the process or who are not submitting claim attachments electronically to review these valuable resources for assistance.
This is a reminder to ensure that you are referring Anthem Blue Cross and Blue Shield (Anthem) members to participating labs. LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs. The relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories. Physicians may continue to refer to all par providers as they have in the past.
Not only does your Anthem agreement obligate you to refer to participating labs where available, but members will only receive their full benefits from participating providers. As a result, referring your patient and our member to a non-participating lab may expose them to a greater financial responsibility.
Unfortunately, there are certain non-participating labs that are offering to waive or cap co-payments, coinsurance or deductibles to our members in order to increase their overall revenue. These practices undermine member benefits and may encourage over-utilization of services.
These billing practices are also questionable in their legality. Such a practice may present violations under state or federal anti-kickback laws.
For a listing of Anthem participating laboratories, please check our online directory. Go to anthem.com. Choose Select Providers, and Providers Overview. Select Find Resources in Your State, and pick Nevada. From the Provider Home tab, select the enter button from the blue box on the left side of page titled Find a Doctor (NV).
Note: When searching for laboratory, pathology, or radiology services, under the field “I am looking for a:” select Lab/Pathology/Radiology; and then under the field “Who specializes in:”, select Laboratories, Pathology, or Radiology as appropriate for your inquiry.
LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs:
LabCorp is capable of providing services that range from routine testing, such as basic blood counts and cholesterol tests, to highly complex diagnosing of genetic conditions, cancers, and other rare diseases. LabCorp has specialized laboratories which cover the following areas of testing:
- Allergy Program
- Cancer Testing
- Cardiovascular Disease
- Companion Diagnostics
- Dermatology
- Diabetes
- DNA Testing
- Endocrine Disorders
- Esoteric Coagulation
- Gastroenterology
- Genetic Testing
- Genetic Counseling
- Genomics
- HLA Lab for National Marrow Donor Program
- Hematopathology
- Infectious Disease
- Immunology
- Liver Disease
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- Kidney Disease
- Medical Drug Monitoring
- Molecular Diagnostics
- Newborn Screening
- Pain Management
- Pathology Expertise w/range of Subspecialties
- Pharmacogenomics
- Preimplantation Genetic Diagnosis
- Reproductive Health
- Obstetrics/Gynecology
- Oncology
- Toxicology
- Whole Exome Sequencing
- Virology
- Women’s Health
- Urology
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Note: This relationship with LabCorp does not affect network hospital-based lab service providers, or contracted pathologists. (NV)
A WISEWOMANTM knows that improving blood pressure is good for the heart
In honor of National High Blood Pressure Education Month, learn more about CDC’s WISEWOMAN program: Well-Integrated Screening and Evaluation for WOMen Across the Nation. The aim of this program is to improve the delivery of heart disease and stroke prevention services for underserved women, aged 40-64 years. The program focuses on cardiovascular disease risk factors, specifically improving high blood pressure1. To learn even more about WISEWOMAN, visit the CDC website.
Resources for your Patients
If your patient is one of the tens of millions of American adults who have hypertension, you know encouraging a healthier lifestyle and prescribing the right medications is important to managing the condition. But, if you would like to provide additional information about high blood pressure to your patients, take advantage of the helpful resources available to healthcare professionals through the CDC. The Hypertension Communications Kit provides blood pressure logs, tip sheets, and more. Hypertension Patient Education Handouts include fact sheets, medication information and dozens of useful tools.
Meeting the HEDIS® measure?
Controlling High Blood Pressure (CBP) assesses adults ages 18-85 with a diagnosis of hypertension and whose blood pressure was properly controlled base on the following criteria
- Adults 18-59 years of age whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg
Patient claims should include one systolic reading and one diastolic reading2:
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CPT II Code
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Most recent systolic blood pressure
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3074F
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<130 mm Hg
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3075F
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130-139 mm Hg
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3077F
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≥ 140 mm Hg
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CPT II Code
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Most recent diastolic blood pressure
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3078F
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<80 mm Hg
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3079F
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80-89 mm Hg
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3080F
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≥ 90 mm Hg
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When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.
Additional tips for talking to patients
- Continue to educate patients about the risks of hypertension
- Encourage weight loss, regular exercise, and diet
- Advise patients who are smoking to quit
- Talk about chronic stress and ways to cope with it in a healthy way
The American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care. Known as the “periodicity schedule,” this screenings and assessments guideline provides a comprehensive schedule for each well-child visit, from infancy.
Schedule for well-child visits
The AAP recommends that children should have a total of eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure. Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures.
Complete coverage for well-child visits
Regardless of when visit is received
Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.
HEDIS® measures W30 and WCV:
Well-child visits in the first 30 months of life (W30)
Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:
- Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
- Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.
Child and adolescent well-care visits
Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
Effective for dates of service on and after May 1, 2021, the following update will apply to the AIM Oncologic Imaging Clinical Appropriateness Guideline as recommended by the United States Preventive Service Taskforce Lung Cancer: Screening statement.
- Expanded low-dose CT screening for ages equal to or greater than 50 and less than or equal to 80 AND 20 or greater pack-year history of cigarette smoking.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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 AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-291-0366, Monday – Friday, 7:00 a.m.– 5:00 p.m. PT.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Material Adverse Change (MAC)
As a reminder, Anthem Blue Cross and Blue Shield (Anthem) announced the delay of a change to our facility reimbursement policy Claims Requiring Additional Documentation in the October 2020 edition of Provider News. The change would have required facilities to submit an itemized bill with outpatient facility claims reimbursed at a percent of charge with billed charges above $20,000. We are raising the billed charges threshold to $50,000 for outpatient and will now implement with dates of service on or after August 1, 2021.
In addition, we are raising the itemized bill requirement for inpatient stay claims threshold from $25,000 to $100,000 and will now implement with dates of service on or after August 1, 2021.
In the January 2021 edition of Provider News, we shared information regarding changes to the Frequency Editing Professional Reimbursement Policy. The notice indicated that constant attendance, timed modalities for physical therapy, occupational therapy or speech therapy are limited to 4 Units or 1 hour per date of service for the same member, by the same provider, per therapy type for (97110 – 97124, 97129, 97130, 97140, 97533 – 97542, 97760 – 97763). Upon further review, we have reconsidered our position and have removed this edit for dates of service on or after April 1, 2021.
As a reminder, Anthem Blue Cross and Blue Shield (“Anthem”) does not allow separate reimbursement for claims that have been identified as a readmission for the same, similar or closely-related diagnoses or condition to the same facility or another facility that (i) operates under the same Facility Agreement, (ii) has the same tax identification number as Facility, or (iii) is under common ownership as Facility, as further described in the existing reimbursement policy found at anthem.com.
If Anthem determines that this reimbursement policy has not been followed, Anthem may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Anthem, and Anthem policies.
Material Adverse Change (MAC)
We are committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.
Effective August 1, 2021, AIM Specialty Health® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the initial evaluation service codes and requested site of service for physical, occupational and speech therapy procedures for Anthem Blue Cross and Blue Shield (Anthem”) fully insured members, as further outlined below.
AIM will continue to manage Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews and will require pre-certification for all outpatient facility and office-based rehabilitative and habilitative services. Prior authorization will now also be required for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and ensure the member is receiving care at the appropriate site of service early in the process. After the evaluation, ongoing services will be subject to site of care review and require prior authorization. AIM will use the following Anthem Blue Cross and Blue Shield (“Anthem”) Clinical UM Guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. The clinical criteria to be used for these reviews can be found on Anthem’s Clinical UM Guidelines page. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, services with diagnosis of autism, and members ages.
A complete list of CPT codes requiring prior authorization for the AIM Rehabilitation program is available on the AIM Rehabilitation microsite. To determine if prior authorization is needed for an Anthem member on or after August 1, 2021, Providers can contact the Anthem Provider Services phone number on the back of the member’s ID card for benefit information. They will be informed whether the AIM Rehabilitation program applies. AIM will also have a file upload from the health plan of the in-scope membership and will not provide pre-certification for members who are out of scope. If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient rehabilitative or habilitative service, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept pre-certification requests for services administered by AIM.)
Members included in the new program
All FI members currently participating in the AIM Rehabilitative program are included. Medicaid members will be included in a separate communication. The following groups are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR, Federal Employee Program® (FEP®).
For self-funded (ASO) groups that currently participate in the AIM Rehabilitative program, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package.
For services provided on or after August 1, 2021, ordering and servicing providers may begin contacting AIM beginning July 19th for review. Providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortallSM 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 AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number at 877-291-0366, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.
Initiating a request on AIM’s ProviderPortalSM for PT/OT/ST and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the Order ID, the number of visits and valid time frame. The AIM Rehabilitation Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM Rehabilitation training webinars
Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to the AIM Rehabilitation microsite to register for an upcoming webinar on June 22nd, July 8th or 27th at 3pm ET. If you have previously registered for other services managed by AIM, there is no need to register again.
We value your participation in our network and look forward to working with you to help improve the health of our members.
To more appropriately align program intention to support member care coordination and to ensure compliance with regulatory requirements surrounding the program, Anthem Blue Cross and Blue Shield (Anthem) is amending the approach for enhanced reimbursement that accompanies selection of ‘on-pathway’ chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program.
Effective July 1, 2021, enhanced reimbursements for medical oncologists selecting on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy authorization process will be adjusted for specific regimens.
Impacted regimens include only select oral and hormonal agents for which a monthly in-office visit may not be required. For these impacted regimens, the optional enhanced reimbursement award, billable using S-codes for treatment planning and care coordination management for cancer, will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353).
This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates.
AIM/Anthem will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support.
For a list of the specific regimens that will be impacted by these changes, please see the attachment.
Contact your Anthem network representative or your oncology provider engagement liaison for more information.
Material Adverse Change (MAC)
In the March 2021 issue of Provider News, we advised we would no longer require prior authorization for the following drugs used to treat ocular conditions effective May 1, 2021. Please be advised that prior authorization will continue to be required for these drugs. We apologize for any inconvenience.
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Drug
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Code
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Code description
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*Avastin
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C9257
J9035
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intravitreal bevacizumab
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*Mvasi
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Q5107
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bevacizumab-awwb
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*Zirabev
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Q5118
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bevacizumab-bvzr
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Material Adverse Change (MAC)
Prior authorization updates
Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the Clinical Criteria information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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**ING-CC-0186
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J3490, J3590, J9999
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Margenza
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*ING-CC-0187
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J3490, J3590, J9999
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Breyanzi
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*ING-CC-0188
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J3490, J3590
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Imcivree
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*ING-CC-0189
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J3490, J3590, C9399
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Amondys 45
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*ING-CC-0190
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J3490, J3590, C9399
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Nulibry
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**ING-CC-0094
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J9304
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Pemfexy
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**ING-CC-0075
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J3590, J9999, C9399
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Riabni
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Prior authorization update – change in clinical criteria
Coding Update: Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.
Quantity limit updates
Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the Clinical Criteria information, click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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|
*ING-CC-0189
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J3490. J3590, C9399
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Amondys 45
|
|
*ING-CC-0190
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J3490, J3590, C9399
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Nulibry
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Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross and Blue Shield (Anthem)-contracted laboratories and identify the proper CPT ® codes to use. Contact your Anthem representative for additional information or visit https://www.anthem.com/medicareprovider.
Refer patients to https://www.anthem.com/coronavirus to find convenient testing locations
If an Anthem member requests a COVID-19 test, you may refer them to Anthem to find a testing location near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:
- Appointment or walk-in
- Drive through service
- Rapid test results
- Antibody testing
- Testing for children
Consider Antigen testing as an option when rapid results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), (for example, PCR). Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
Send swab tests to Anthem-contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high-value healthcare.
Please continue to check Medicaid Provider Communications & updates at www.anthem.com/nymedicaiddoc for the latest Medicaid information, including:
Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines. Part of the AIM Specialty Health ®* (AIM) guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe and affordable healthcare services.
Advanced imaging of the spine (updates by section)
- Congenital vertebral defects
- New requirement for additional evaluation with radiographs
- Scoliosis
- Defined criteria for which presurgical planning is indicated
- Requirement for radiographs and new or progressive symptoms for postsurgical imaging
- Spinal dysraphism and tethered cord
- Diagnostic imaging strategy limiting the use of CT to cases where MRI cannot be performed
- New requirement for ultrasonography prior to advanced imaging for tethered cord in infants age five months or less
- Multiple sclerosis
- New criteria for imaging in initial diagnosis of multiple sclerosis
- Spinal infection
- New criteria for diagnosis and management aligned with Infectious Diseases Society of America and University of Michigan guidelines
- Axial spondyloarthropathy
- Defined inflammatory back pain
- Diagnostic testing strategy outlining radiography requirements
- Cervical injury
- Aligned with the American College of Radiology (ACR) position on pediatric cervical trauma
- Thoracic or lumbar injury
- Diagnostic testing strategy emphasizing radiography and limiting the use of MRI for known fracture
- Removed indication for follow-up imaging of progressively worsening pain in the absence of fracture or neurologic deficits
- Syringomyelia
- Removed indication for surveillance imaging
- Non-specific low back pain
- Aligned pediatric guidelines with ACR pediatric low back pain guidelines
Advanced imaging of the extremities (updates by section)
- Osteomyelitis or septic arthritis; myositis
- Removed CT as a follow-up to nondiagnostic MRI due to lower diagnostic accuracy of CT
- Epicondylitis and tenosynovitis — long head of biceps
- Removed due to lack of evidence supporting imaging for this diagnosis
- Plantar fasciitis and fibromatosis
- Removed CT as a follow-up to nondiagnostic MRI due to lower diagnostic accuracy of CT
- Added specific conservative management requirements
- Brachial plexus mass
- Added specific requirement for suspicious findings on clinical exam or prior imaging
- Morton’s neuroma
- Added requirements for focused steroid injection, orthoses, plan for surgery
- Adhesive capsulitis
- Added requirement for planned intervention (manipulation under anesthesia or lysis of adhesions)
- Rotator cuff tear; labral tear shoulder; labral tear hip
- Defined specific exam findings and duration of conservative management
- Recurrent labral tear now requires same criteria as an initial tear (shoulder only)
- Triangular fibrocartilage complex tear
- Added requirement for radiographs and conservative management for chronic tear
- Ligament tear — knee; meniscal tear
- Added requirement for radiographs for specific scenarios
- Increased duration of conservative management for chronic meniscal tears
- Ligament and tendon injuries — foot and ankle
- Defined required duration of conservative management
- Chronic anterior knee pain, including chondromalacia patella and patellofemoral pain syndrome
- Lengthened duration of conservative management and specified requirement for chronic anterior knee pain
- Intra-articular loose body
- Requirement for mechanical symptoms
- Osteochondral lesion (including osteochondritis dissecans, transient dislocation of patella)
- New requirement for radiographs
- Entrapment neuropathy
- Exclude carpal and cubital tunnel
- Persistent lower extremity pain
- Defined duration of conservative management (6 weeks)
- Exclude hip joint (addressed in other indications)
- Upper extremity pain
- Exclude shoulder joint (addressed in other indications)
- Diagnostic testing strategy limiting use of CT to when MRI cannot be performed or is nondiagnostic
- Knee arthroplasty, presurgical planning
- Limited to MAKO and robotic assist arthroplasty cases
- Perioperative imaging, not otherwise specified
- Require radiographs or ultrasound prior to advanced imaging
Vascular imaging (updates by section)
- Alternative nonvascular modality imaging approaches, where applicable
- Hemorrhage, intracranial
- Clinical scenario specification of subarachnoid hemorrhage indication.
- Addition of Pediatric intracerebral hemorrhage indication.
- Horner’s syndrome; pulsatile tinnitus; trigeminal neuralgia
- Removal of management scenario to limit continued vascular evaluation
- Stroke/transient ischemic attack; stenosis or occlusion (intracranial/extracranial)
- Acute and subacute timeframe specifications; removal of carotid/cardiac workup requirement for intracranial vascular evaluation; addition of management specifications
- Sections separated anatomically into anterior/posterior circulation (carotid artery and vertebral or basilar arteries, respectively)
- Pulmonary embolism
- Addition of nondiagnostic chest radiograph requirement for all indications
- Addition of pregnancy-adjusted YEARS algorithm
- Peripheral arterial disease (PAD)
- Addition of new post-revascularization scenario to both upper and lower extremity PAD evaluation
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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 AIM via the Availity* Portal at availity.com. From Availity’s home page, select Patient Registration > Authorizations & Referrals. The AIM Specialty Health link is located below Additional Authorizations and Referrals.
- Call the AIM Contact Center toll-free number at 1-800-714-0040 Monday - Friday from 7 a.m. and 7 p.m. Eastern time.
Questions
If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Jennifer C. Moore, MSW, LCSW, Inc., doing business as Foundations Counseling Center, was incorporated in 2003 by Jennifer Moore. Prior to establishing a group practice, Jennifer worked in mental health inpatient and outpatient facilities, group home settings, and residential treatment centers. Graduating in 1994 with Highest Honors from the University of California, Santa Barbara with a bachelor’s degree in Psychology, Moore has been awarded the Katherine Esau Award and the Chairperson’s Award in Psychology. In 1996, she was awarded scholarships to attend the University of Nevada, Las Vegas and graduated in 1998 with a master’s degree in Social Work. Since then, Jennifer has taken an active role within the Las Vegas community, not only building her practice to affect positive change within people, but also supporting and volunteering her time for various charities throughout the valley. To date, Jennifer has had over 30 years of experience in the mental health field.
What began as just a private practice in 2003 has quickly grown to become a highly-regarded group practice and agency within the community. Today, Foundations Counseling Center is made up of nine mental health providers and two office staff employees (see photo listing providers). Foundations Counseling Center had always offered outpatient mental health services in the northwest part of Las Vegas, Nevada, but as of January 2021, Foundations Counseling Center has expanded and collaborated with Focus Mental Health Solutions to provide services together under one roof in Henderson, Nevada.
Through the years, Foundations Counseling Center has provided high quality care to help clients with a wide range of presenting problems — including suicidal ideation, self-mutilation, depression, anxiety, eating disorders, adjustment disorders, trauma-related issues, ADHD, behavioral issues, bipolar disorder and a multitude of presenting concerns. Foundations Counseling Center specializes in working with children and adolescents, but sees individuals, couples and families of all ages.
Foundations Counseling Center values the uniqueness of each individual. Although they tend to utilize cognitive-behavioral techniques in practice, they are eclectic in their approach and develop treatment plans that best meet the specific needs of their clients. Focusing on symptoms versus labels, solutions rather than problems, and recognizing the significant relationship between a person and their environment are how Foundations Counseling Center manages to help all clients actualize their potential and achieve their goals.
(In group photo from left to right: Susan Woolf, CSW-I; Jacob Lockhart; Shayla Williams, CSW-I; Lisa Roberson, LCSW; Jennifer Moore, LCSW; Elizabeth Arellano, CSW-I; Frances Young, LCSW; Steven Antolin, CSW-I; Kelly Cox. (Not pictured: Natasha Mosby, LCSW; Jody Williams, LCSW)
Each quarter, Anthem Blue Cross and Blue Shield Healthcare Solutions will feature one of our amazing providers. This feature is meant to highlight the diversity in our network and the membership we serve. We can also highlight shared best practices. If you would like to be considered, please email your Provider Experience consultant.
You only need to write in once. We will revisit submissions each quarter. Thank you for all the work that you do!
Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
The Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) HEDIS® measure evaluates the percentage of children and adolescents 1 to 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.
Antipsychotic medications can increase a child’s risk for developing health concerns, including metabolic health complications. The goal of this measure is for members to have metabolic monitoring by having both a blood glucose test (glucose or HbA1c) and LDL-C testing annually.
Record your efforts:
- Glucose test or HbA1c test and LDL-C cholesterol test as identified by claim/encounter
- Document results in the member’s medical record
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
The Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) HEDIS measure evaluates members 18 to 64 years of age with schizophrenia, schizoaffective disorder or bipolar disorder, and who were dispensed an antipsychotic medication and had a diabetic screening test during the measurement year.
Diabetes screening is important for anyone with schizophrenia or bipolar disorder. The added risk associated with antipsychotic medications contributes to the need to screen people with schizophrenia for diabetes annually.
Record your efforts:
- Glucose test or HbA1c test as identified by claim/encounter
- Document results in the member’s medical record
Helpful tips:
- Educate patients and their caregivers on the importance of completing blood work annually.
- If your practice uses electronic medical records (EMRs), have flags or reminders set in the system to alert when a patient is due for screenings.
- Draw labs in your office, if available, or refer members to a participating lab for screenings.
- Follow up on laboratory test results and document in your chart.
- Share EMR data with Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) to capture all coded elements.
Other available resources:
- Clinical Practice Guidelines are available on our provider website at https://mediproviders.anthem.com/nv.
- For The Quality Measures Desktop Reference for Medicaid Providers and HEDIS Benchmarks and Coding Guidelines for Quality Care, contact Anthem Provider Services.
For more information, call Provider Services at 1-844-396-2330 or contact your local Provider Solutions representative
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