Background

We previously shared details about an enhancement to the medical claims editing system for pharmaceutical drug procedure codes. This improvement ensures that claims align with FDA‑approved or off‑label indications, based on the list of pharmaceutical compendia defined by CMS. This change aims to promote accuracy in claims and improve reimbursement efficiency.

Provider impact

Beginning with claims processing on or after June 1, 2025, we will introduce additional drug procedure codes into our system. Codes requiring preapproval or those tied to specific medical policies will not be affected by this update.

Note: A drug procedure code will not be approved if the diagnosis reported is not an approved indication.

If you would like your claim decision reviewed, follow the claims dispute process outlined in the provider manual. You must include relevant medical record details regarding the drug provided for faster resolution.

If you have questions about this notification, contact your contract manager or provider relationship management representative.

Thank you for your cooperation and commitment to improving member care.

Annual wellness and well-woman visits are covered with no member cost-sharing when provided by in-network providers for our members with Affordable Care Act (ACA)compliant plans. Individual and small group plan members are encouraged to schedule these visits within the first 90 days of their plan starting or renewing, so your practice may see an increase in requests, especially at the beginning of the second and fourth quarters.

Providers can perform the annual wellness or well‑woman visit, even if it has been less than one calendar year since the last wellness visit. We ask that your practice be flexible in accommodating members wanting to schedule their visits earlier than they may have previously. The wellness or well‑woman visit claim will be processed as a preventive care service covered with no member cost share.

Please note that this benefit may not apply to all health plans. You should continue to verify eligibility and benefits for all members in Availity Essentials (https://Availity.com) before providing services or receiving member copayments, deductibles, or coinsurance.

We are excited to announce the opening of West Henderson Hospital, a state‑of‑the‑art facility designed to serve the growing healthcare needs of our community. This innovative hospital features the latest medical technology and comprehensive services, including a full‑service emergency department, advanced inpatient and outpatient surgical suites, diagnostic imaging, and specialized care services.

West Henderson Hospital is now accessible to all members across various lines of business, ensuring increased access to care and streamlined patient coordination. We look forward to this new opportunity to support you in providing exceptional healthcare to your patients — our members.

Provider Pathways supports the delivery of high‑quality services and value to our members by giving you instant access to premium learning tools and educational resources. The platform’s flexibility empowers you to choose the pace and topics that best suit your needs.

What does Provider Pathways offer?

• On‑demand training, available 24/7
• Microlearning modules — concise, convenient lessons on a variety of topics
• Specific information essential to our partnership

Recent enhancements:

• More topics and content to explore
• A new, user‑friendly menu and navigation experience
• Improved accessibility features:
• Closed captioning
• Voice actors
• Original transcriptions

Please visit the Training Academy to access Provider Pathways and review the modules available.

Manage your prior authorization requests with our digital tools — Availity Essentials and https://anthem.com/provider. These resources simplify requirement determination and request submissions, giving you more time to deliver effective and efficient care to our members. We encourage you to review the instructions below.

Determining prior authorization requirements

Availity Essentials:

1. Log in to https://Availity.com.
• If you do not already have access, select Get Started to create an account.
2. Go to the Payer Spaces tab.
3. Select the applicable plan.
4. Select Authorization Rules Lookup.
5. Enter the required provider information.
6. Select Next and enter the required member information.

Note: Final determination of prior authorization requirements is completed upon submission and may differ from search results.

Provider website:

1. Go to https://anthem.com/provider.
2. Scroll down and select the applicable state.
3. Scroll down to Commercial‑partnered programs and select Access the Commercial Provider site to access the Provider website homepage.
4. Under the Resources heading, select Prior Authorization.
5. Select the applicable state.
6. Select the appropriate link based on the member’s plan.

If the member’s home plan is not with Anthem, scroll to Helpful Links > Select Medical Policy and Prior Authorization for Blue Plans, then follow the prompts to determine the applicable home plan and prior authorization requirements.

Submitting prior authorization requests

Availity Essentials:

1. Log in to https://Availity.com.
2. Select the Patient Registration tab to access Authorizations and Referrals.
3. Select Authorization Request.

Note: Transplant prior authorization requests must be submitted by phone, fax, or secure email.

Anthem is happy to support the announcement of an exciting partnership between Premera Blue Cross, Amazon, and the American College of Lifestyle Medicine (ACLM) offering a free online Lifestyle Medicine & Food as Medicine Essentials Course for the entire provider community.

In this comprehensive online course, you will explore the six pillars of lifestyle medicine, emphasizing how food and nutrition can play a critical role in preventing and treating chronic diseases. The course is tailor‑made for healthcare providers looking to enrich their care approach with practical evidence‑based strategies. This course is available until September 14, 2025.

Benefits for providers:

• Free access: Participate in this valuable training at no cost.
• Earn credits: Completing the course awards, you earn 5.5 CME/CE credits.
• Enhance your practice: Acquire tools to transform care and effectively address chronic disease.

How to enroll:

1. Visit https://lifestylemedicine.org/essentials.
2. Log in or create an ACLM account.
3. Enter promo code ESS‑AMZNEDU at checkout to access the course for free.

Contact us

Please reach out to Dr. Jon Liu at jonliu@amazon.com with questions regarding the free course.

Effective on May 2, 2025, Anthem will transition to the following Carelon Medical Benefits Management Clinical Appropriateness Guidelines. 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 guidelines have a publish date of April 1, 2025:

• Cardiovascular:
• Ambulatory Cardiac Rhythm Monitoring
• Electrophysiological Studies
• Dialysis Access Evaluations
• Vascular Embolization and Occlusion Procedures

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.

Effective on May 3, 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 3/23/2025:

• Genetic Testing
• Somatic Tumor Testing

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.

Effective on May 10, 2025, Anthem will transition to the following Carelon Medical Benefits Management Clinical Appropriateness Guidelines. 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 guidelines have a publish date of April 1, 2025:

• Cardiovascular:
• Ambulatory Cardiac Rhythm Monitoring
• Electrophysiological Studies
• Dialysis Access Evaluations
• Vascular Embolization and Occlusion Procedures

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

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

Effective 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 preapproval requirements have not changed. In the event of implementation of a preapproval requirement for these services, a separate notice will be distributed before the addition of preapproval 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.

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 Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements; new document number

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

Please 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 inform the provider of new or revised criteria that have been adopted by the health plan only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.