We conducted our in-person Provider Seminars in Reno and Las Vegas in October.  In case you missed either of them, or just if you prefer a webinar option, we still have opportunities for you to participate.  We are offering 4 webinar sessions throughout November. 

 

Please join us for one of our upcoming provider webinars. These sessions include important information about doing business with us, and updates since our last series of seminars. Topics include:

Network News and Updates, Product overview for 2019, Medicaid Updates, Commercial Risk Adjustment program overview, Member ID card changes, New Provider newsletter/communication template, Anthem.com Provider website enhancements, Availity Portal enhancements, plus more!

 

NOTE: The content covered in the Provider Seminars and Webinars is the same, but we split the webinars into two content parts to make the online learning experience a little easier and shorter length. 

 

For dates and times, see the attached Provider Seminar Invitation.

 

The online registration includes automated acknowledgement of your registration, an appointment to add to your calendar, and reminder notifications.  Don’t forget to accept the calendar appointment to add it to you calendar. 

 

Register online using one of the following options:    

 

Go to anthem.com. Select Providers, then Providers Overview.  Select Find Resources for Your State, and pick Nevada.  From the Provider Home page, under the Communications and Updates heading, select the Provider Seminars link.  Next, under the Fall 2018 Provider Seminars heading, select the link titled Fall 2018 Provider Seminar Invitation -- online registration form, select either IN-PERSON or WEBINARS.

We are pleased to share that Paul Marchetti has been named Senior Vice President, Network and Care Delivery Transformation for Anthem. Paul joined Anthem October 22 and will have responsibility for Anthem’s overall care transformation strategy.

 

Paul is a respected leader who has more than 25 years of payer and provider experience in healthcare delivery systems, business operations, product development and population health, and technology solutions. Paul joins Anthem from New Century Health, a specialty care management company, where he served as Chief Growth Officer and led top-line revenue growth, strategic planning and execution and product development. Prior to his current role, Paul held leadership roles at Aetna, United HealthCare, Horizon Healthcare and Physicians Health Services.

 

Paul looks forward to meeting and engaging with our healthcare professionals and payers to evolve the healthcare system to one that is simpler, more accessible and more affordable for all Americans.

Effective October 14, 2018, Anthem Blue Cross and Blue Shield (Anthem) will enforce the requirement to bill the correct modifier and HCPCS for services utilized.  Incorrect billing will be rejected and claims will be returned to the provider for correction and resubmittal.

 

Durable Medical Equipment (DME) may be purchased, rented or rented until the purchase price has been paid. 

 

Correct billing will allow member benefits to be applied correctly to include benefit accumulations for a member’s DME benefits.

The Prefix Reference List has been updated. Access the updated list online. Please go to anthem.com.  Select Provider, and Providers Overview. Select Find Resources for Your State, and pick Nevada.  From the Provider Home page, under the Self Service and Support heading, choose Contact Us (Escalation Contact List & Alpha Prefix List), and then Prefix Reference List.

The Prefix Reference List has been updated. Access the updated list online. Please go to anthem.com.  Select Menu, and under the Support heading, select Providers.  Select Find Resources for Your State, and pick Nevada.  From the Provider Home page, under the Self Service and Support heading, choose Contact Us (Escalation Contact List & Alpha Prefix List), and then Escalation Contact List.

We invite you to go to anthem.com to learn about the many ways health care reform and health insurance marketplace / affordable care act information may impact you. New information is added regularly. To view the latest articles on health care reform and/or health insurance marketplace / affordable care act, and all achieved articles, go to anthem.com. Select Providers, and Providers Overview. Select Find Resources in Your State, and pick Nevada.  Select the Provider Home tab at the top of the page.  Under the Communications and Updates heading, choose Health Care Reform Updates and Notifications or Health Insurance Exchange Marketplace / Affordable Care Act information.

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

 

• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila
• July Medicare Advantage reimbursement policy
• Submit PA medication requests electronically; new phone number for MA prescription PAs
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective January 1, 2019
• Inpatient Readmissions
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective September 1
• Introducing the Interactive Care Reviewer

Every year, somewhere between five and twenty percent of the population contract the flu. Last year’s flu season was one of the worst in recent memory, and some experts are predicting that this year will follow the same pattern. 

 

Anthem Blue Cross and Blue Shield (Anthem) is trying to help members locate alternatives to Emergency Rooms for care that does not require an Emergency Room setting.  Frequently the services these patients need are not emergent and sometimes not even urgent. 

As flu season approaches, we are trying to help you know alternatives available for your Anthem patients when they are unable to see their Primary Care Provider or other treating provider.

 

Urgent Care Centers and ER Alternatives

 

Anthem’s provider directories currently include Urgent Care centers, Retail Health Clinics, and Walk-in Doctor’s Offices. 

 

If it's not an emergency and the member can't get to his/her regular doctor, he/she may be able to get the care needed -- and save time and money with these other types of quick-care options.

• Urgent Care Centersare staffed with family, pediatric, ER and internal medicine doctors. They treat certain conditions right away that are not as severe as emergencies.
• Retail Health Clinicsare often found in a major pharmacy or retail store. They have physician assistants and nurse practitioners onsite to treat basic health concerns.
• Walk-in Doctors' Officesare usually family practice doctors who can treat many things even if the member is not a regular patient or have an appointment.

 

Members should always call 911 or go the Emergency Room (ER) if he/she thinks they are having a real emergency or if the member thinks it could put their health at serious risk by delaying care.

 

Access our online Provider Directory at https://www.anthem.com/find-doctor/.

 

DispatchHealth - Las Vegas only

 

While we encourage members to utilize urgent care centers as lower cost options to an Emergency Room (ER) visit when appropriate, we’re also offering our Anthem network providers a convenient solution to the ER alternatives listed above.  This new option may be especially helpful for members that may have issues leaving home. 

 

DispatchHealth travels so the flu doesn’t. They bring high-quality care to your patients’ homes when acute needs arise after hours or during busy clinic days, and their board-certified medical teams will fully document your patients’ visits and send detailed clinical notes directly to you.

 

For cases of the flu, their medical team -- also referred to as this season’s “Traveling Flu Crew” -- will arrive ready to perform a rapid infectious disease test, administer IV fluids, prescribe anti-nausea medication, prescribe antivirals if caught early enough, and order a chest x-ray if pneumonia is suspected.

 

Each DispatchHealth medical team consists of either a physician assistant or nurse practitioner, along with a medical technician and on-call physician. There’s no added cost to your practice. 

 

DispatchHealth will bill Anthem directly for the care provided, just like an urgent care. A visit with DispatchHealth typically costs 80-90 percent less than the average emergency room visit.

 

You can refer a patient to DispatchHealth when you’re on-call, after hours and on weekends and holidays. Your patients can also request care from DispatchHealth directly by simply calling 702-848-4443.

 

To learn more, visit dispatchhealth.com.

The Centers for Medicare & Medicaid Services has increased its emphasis on the appropriate use of statins among Medicare Advantage (MA) beneficiaries diagnosed with diabetes and cardiovascular disease. Please evaluate whether your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

 

The 2013 American College of Cardiology and the American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events. High-intensity statin therapy is recommended if the patient has an estimated 10-year ASCVD risk ≥7.5 percent. For males 21-75 and females 40-75 years of age with clinical ASCVD, high-intensity statin therapy is recommended unless contraindicated.  These guidelines recommend statin therapy in these scenarios regardless of the patient’s LDL values.  Please evaluate if your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

 

Formulary agents are listed below:

 

Therapy intensity	Drug (brand)	Dose
Moderate-intensity statin therapy (formulary agents)	atorvastatin**	10 mg, 20 mg
	rosuvastatin*	5 mg, 10 mg
	simvastatin**	20 mg, 30 mg, 40 mg
	pravastatin**	40 mg, 80 mg
	lovastatin**	40 mg
High-intensity statin therapy (formulary agents)	atorvastatin**	40 mg, 80 mg
	rosuvastatin*	20 mg, 40 mg

 

*Rosuvastatin (Crestor) is a preferred brand medication on the Medicare formulary. 

 

**Available for a $0 co-pay for most plans in 2018

Effective January 1, 2019, prior authorization (PA) requirements will change for injectable/infusible drug Somatrem to be covered by Anthem Blue Cross and Blue Shield Healthcare Solutions. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

• Somatrem — injection, 1 mg (J2940)

 

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone:  1-844-396-2330 

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-844-396-2330 for PA requirements.

 

ANV-NU-0003-18 September 2018

Effective October 15, 2018, Medicaid claims received by Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) containing procedure codes not priced by the fee schedule listed in your Provider Agreement may be denied or pended for further review.

 

To avoid claim denials, please ensure you’re billing with the most current, applicable procedure code.

 

Why is this change necessary?

 

We have paid certain claims at 15 or 30 percent of billed charges, which is outlined as Market Terminal Pricing and/or Contracted Terminal Pricing on the Explanation of Payment. This occurs when a claim is submitted with a CPT or HCPCS code (with or without modifier) that is not priced or not listed on the fee schedule on which your Provider Agreement is based. This includes a specific revenue code billed with and/or without a service code that is not covered under NV Medicaid.

 

We identified that paying a percentage of charges for these services may not be accurate. In many cases, the service is:

• Not a covered benefit.
• Billed with an invalid procedure code (or procedure/modifier combination).
• An unlisted code that should be priced manually.
• A code not separately reimbursed.
• A different code used by state Medicaid with a fee allowance for the service and/or item.

 

What is the impact of this change?

 

To ensure accurate processing of claims going forward, any procedure code billed that is not listed on the applicable fee schedule(s) will be denied or pended for further information.

 

You may receive a claim denial if you do not bill with the most current, applicable procedure codes to reflect the services rendered, per your Provider Agreement and fee schedules. Claims billed in line with the fee schedule will be processed accordingly.

 

What if I need assistance?

 

If you have questions about this communication, received this fax in error or need help with any other item, contact your local Provider Relations representative or call Provider Services at 1‑844-396-2330.

 

ANV-NU-0012-18 September 2018

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Note:

• Effective July 30, 2018, InterQual® 2018 and 2018.1 releases will be used. InterQual will continue to be used for home care criteria, long-term care criteria, rehabilitation criteria, and subacute and skilled nursing facilities.

 

• Effective November 1, 2018, MCG Health Care Guidelines will be used for reviews, to include the use of customizations to certain guidelines and:
  • o Inpatient and Surgical Care Guidelines.
  • o General Recovery Care Guidelines.
  • o Recovery Facility Care Guidelines.
  • o Chronic Care Guidelines.
  • o Behavioral Health Care Guidelines (NEW).

 

• Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.

 

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

 

To search for specific policies or guidelines, visit http://www.anthem.com/cptsearch_shared.html.

 

Medical Policies

 

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).

 

Publish date	Medical Policy number	Medical Policy title	New or revised
6/6/2018	DRUG.00098	Lutetium Lu 177 dotatate (Lutathera®)	New
6/6/2018	DRUG.00046	Ipilimumab (Yervoy®)	Revised
5/10/2018	DRUG.00047	Brentuximab Vedotin (Adcetris®)	Revised
5/10/2018	DRUG.00053	Carfilzomib (Kyprolis®)	Revised
6/6/2018	DRUG.00071	Pembrolizumab (Keytruda®)	Revised
6/6/2018	DRUG.00075	Nivolumab (Opdivo®)	Revised
5/10/2018	DRUG.00076	Blinatumomab (Blincyto®)	Revised
6/6/2018	DRUG.00111	Monoclonal Antibodies to Interleukin-23	Revised
5/10/2018	SURG.00026	Deep Brain, Cortical and Cerebellar Stimulation	Revised

 

Clinical UM Guidelines

 

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
6/6/2018	CG-LAB-12	Testing for Oral and Esophageal Cancer	New
6/6/2018	CG-MED-71	Wound Care in the Home Setting	New
6/28/2018	CG-DME-44	Electric Tumor Treatment Field (TTF)	New
6/28/2018	CG-DRUG-67	Cetuximab (Erbitux®)	New
6/28/2018	CG-DRUG-94	Rituximab (Rituxan®) for Nononcologic Indications	New
6/28/2018	CG-DRUG-95	Belatacept (Nulojix®)	New
6/28/2018	CG-DRUG-96	Ado-trastuzumab emtansine (Kadcyla®)	New
6/28/2018	CG-DRUG-97	Rilonacept (Arcalyst®)	New
6/28/2018	CG-DRUG-98	Bendamustine Hydrochloride	New
6/28/2018	CG-DRUG-99	Elotuzumab (Empliciti™)	New
6/28/2018	CG-DRUG-100	Interferon gamma-1b (Actimmune®)	New
6/28/2018	CG-DRUG-101	Ixabepilone (Ixempra®)	New
6/28/2018	CG-DRUG-102	Olaratumab (Lartruvo™)	New
6/28/2018	CG-MED-72	Hyperthermia for Cancer Therapy	New
6/28/2018	CG-SURG-76	Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty	New
6/28/2018	CG-SURG-77	Refractive Surgery	New
6/28/2018	CG-SURG-78	Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies	New
6/28/2018	CG-SURG-79	Implantable Infusion Pumps	New
6/28/2018	CG-SURG-80	Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors	New
5/10/2018	CG-DRUG-50	Paclitaxel, protein bound (Abraxane®)	Revised
6/6/2018	CG-DRUG-60	Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications	Revised
6/6/2018	CG-DRUG-62	Fulvestrant (FASLODEX®)	Revised
6/6/2018	CG-DRUG-78	Antihemophilic Factors and Clotting Factors	Revised

 

ANV-NL-0038-18 September 2018