 Provider News NevadaNovember 1, 2022 November 2022 Anthem Provider News - NevadaProviders currently submit prior authorization (PA) requests to AIM Specialty Health ®* (AIM) for outpatient diagnostic imaging services. These PA requests are often reviewed based on provider attestation of certain requirements.
As part of our ongoing quality improvement efforts, we want you to know that as of January 1, 2023, some review requests may require documentation to substantiate the attestations that support the clinical appropriateness of the request. This documentation can be uploaded during the intake process.
When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the PA review attestations.
If the request would be denied as not medically necessary, providers can participate in a PA discussion with an AIM physician reviewer.
As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting them to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.
Anthem Blue Cross and Blue Shield (Anthem) would like to make you aware of a change to our professional fee schedule that will be effective for dates of service on or after January 1, 2023.
Effective January 1, 2023, Anthem will move from the 2017 Resource Based Relative Value Scale (RBRVS) to the January 2022 RBRVS.
Please note, the Medicare conversion factor and relative value units are rounded from four decimal points to two decimal points.
If you have any questions about this fee schedule change or need assistance with any other item, use the chat feature in Availity,* call Provider Services at 844-396-2330, or use the Contact Us feature on our website at https://providers.anthem.com/nevada-provider/contact-us/email to submit an inquiry to our Healthcare Network team. All inquiries will be responded to within 48 hours.
Thank you for your participation in our networks and for the care you provide your patients and our members.
This communication applies to the Medicaid program from Anthem Blue Cross and Blue Shield Healthcare Solutions and the Commercial programs from Anthem Blue Cross and Blue Shield (Anthem) in Nevada.
Anthem suggests providers review the Pediatricians and Family Physicians Toolkit for resources on increasing confidence in and uptake of COVID-19 vaccines among youth. Developed in partnership with the American Academy of Pediatrics, the toolkit includes information from the CDC and new, culturally tailored materials from the Health and Human Services (HHS) COVID-19 Public Education Campaign and its team of multicultural experts.
For additional information regarding the COVID-19 vaccine uptake among youth, see the following HHS website: https://wecandothis.hhs.gov/resource/pediatricians-and-family-physicians-toolkit.
This communication applies to the Medicaid program from Anthem Blue Cross Blue Shield Healthcare Solutions, the Medicare Advantage, and Commercial programs from
Anthem Blue Cross and Blue Shield (Anthem) in Nevada.
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered by Anthem.
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.
FAQ
How does Anthem retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.
Why does Anthem need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.
Accessing claim statuses
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
Working together to streamline processes through technology is a collaborative effort. We appreciate your feedback as we continue improving to meet your expectations. The enhancements we’ve made to the Availity Essentials* Authorization application make it faster, easier, and more efficient to submit digital authorizations for Anthem Blue Cross and Blue Shield members.
View attachments for authorizations submitted — You can now view the attachments you’ve submitted to support your authorization in the Availity Essentials authorization application.
Servicing and rendering provider — We’ve enhanced the Availity Essentials Authorization Application to enable a group option when selecting the servicing and rendering provider.
View correspondence — Access status and decision letters right from the Authorization Application Dashboard. Letters can also be downloaded or printed if needed.
Enhanced provider status — Out-of-network and in-network provider statuses are now enhanced to return fewer errors associated with provider status.
Expanded search — Search rendering and serving provider by NPI and ZIP code for quicker results.
Procedure code enhancement — Add the procedure code on an outpatient authorization for more accurate submission.
Case update features — You can now update your authorization right from your Authorization Application Dashboard.
Training sessions on the Availity Essentials authorization application are still available
Whether you prefer live training webcasts, on-demand webinar recordings, or a resource guide, we have everything you need to learn more about the Availity Essentials Authorization Application and how to make the most of it. Use this link to access the training option best for you.
The next live webcast is Wednesday, November 9, 2022, at 11 a.m. ET. Register here.
When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for Anthem Blue Cross and Blue Shield claims
The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven-calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven-calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.
We incorrectly published this article in the November 2022 issue of Provider News. The digital dispute function is not currently available in Nevada on Availity.com.
Submitting Anthem Blue Cross and Blue Shield claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
New learnings added to the Provider Learning Hub.
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
This is a reminder for you to refer Anthem members to participating labs whenever possible. Referring Anthem members to a nonparticipating lab may expose them to a greater financial responsibility. LabCorp* is our preferred lab provider and is a single-source solution for your testing requirements. LabCorp referrals do not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories. Physicians can continue to refer to all participating lab providers as they have in the past.
In your Anthem Agreement you agreed to refer Anthem members to participating labs when available. This is important because members will only receive their full benefits from participating lab providers. As a reminder, Quest Diagnostics* is a nonparticipating laboratory for all lines of business in Colorado.
There are certain nonparticipating labs offering to waive or cap co-payments, coinsurance, or deductibles for our members.
These practices undermine member benefits and represent questionable billing practices. Referring to LabCorp assures our members their lab costs will be covered under their benefit terms.
For a listing of Anthem participating laboratories, please check our online directory. Go to https://www.anthem.com, select For Providers, and select Go To Providers Overview. From here, select Find Resources in Your State, and choose Nevada. From the Provider Home tab, select the enter button from the blue box on the right side of page titled Find Care.
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 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
- Kidney disease
- Medical drug monitoring
- Molecular diagnostics
- Newborn screening
- Pain management
- Pathology expertise with range of subspecialties
- Pharmacogenomics
- Preimplantation genetic diagnosis
- Reproductive health
- Obstetrics/gynecology
- Oncology
- Toxicology
- Whole exome sequencing
- Virology
- Women’s health
- Urology
|
To find a LabCorp location near you, go to https://www.labcorp.com or call one of the phone numbers below.
For information about specialized assays or about requirements for special collection kits and specimen handling, call LabCorp at 303-792-2600 or toll free at 888-LABCORP (888-522-2677).* LabCorp is an independent company providing laboratory services on behalf of Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NVBCBS-CRCM-006330-22-SRS5940 Effective November 6, 2022, Anthem Blue Cross and Blue Shield will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health ®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
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 https://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 Availity* at availity.com.
For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Additionally, you may access and download a copy of the current and upcoming guidelines here.
As you may be aware, the U.S. Preventive Services Task Force (USPSTF) issued updated guidelines recommending screening for colorectal cancer to begin at age 45. 1 The USPSTF considers highly sensitive fecal occult blood tests (FOBT) as a good option for colorectal cancer screening. The FDA has approved fecal immunohistochemical testing (FIT also known as iFOBT) for ectal cancer screening in average risk patients. When FIT is performed at the recommended intervals, it has similar specificity and sensitivity to stool-based DNA tests.
Labcorp* is our preferred lab provider and has a cost-effective colorectal cancer screening option that provides high sensitivity and specificity while enabling patient ease, convenience, and satisfaction. You can improve patient compliance for colorectal cancer screening with Labcorp’s fecal immunohistochemical testing (FIT) kit. Labcorp’s FIT kit provides your patients with everything they need to complete the sample collection at home and mail it back to Labcorp. In addition, the kit is easy to use, requiring no special preparation or direct stool contact.
When you use Labcorp you’ll have:
- Electronic delivery of results to your electronic medical records (EMR) system, making documentation of screening results easier for you and your office staff.
- Patient friendly in-home collections.
- 99.1% sensitivity and 100% specificity,2 resulting in a high-quality test.
For more information
To obtain FIT kits for your office or for more information, contact your local Labcorp sales representative. You can also visit www.labcorp.com/cancer/colorectal/providers for additional ordering details.
Material adverse change (MAC)
In the July edition of Provider News, we announced a Place of Service — Facility reimbursement policy indicating that evaluation & management (E/M) services and other professional services must be billed on a CMS-1500 claim form and are not reimbursable when billed on a UB-04 claim form (excluding E/M services rendered in an emergency room and billed with ER revenue codes).
It has come to our attention that some of the preventive counseling CPT® codes mentioned in the July article were listed incorrectly. The correct preventive counseling CPT codes are 99401–99404, 99411, and 99412, and are not reimbursable when billed in an outpatient setting of a facility effective with dates of service on or after February 1, 2023.
Please note, however, that the revenue codes 960-983 and the E/M services noted in the July edition were listed correctly in the Place of Service — Facility reimbursement policy effective with dates of service on or after October 1, 2022.
For specific policy details, visit the reimbursement policy page on our anthem.com/provider website.
NVBCBS-CM-009519-22-CPN9003 Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
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.
Prior authorization updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
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Fylnetra (pegfilgrastim-pbbk)
|
J3590
|
|
ING-CC-0002*
|
Rolvedon (eflapegrastim-xnst)
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C9399, J3490, J3590
|
|
ING-CC-0002*
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Stimufend (pegfilgrastim-fpgk)
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C9399, J3490, J3590
|
|
ING-CC-0072
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Cimerli (ranibizumab-cqrn)
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J3590
|
|
ING-CC-0220
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Xenpozyme (olipudase alfa)
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C9399, J3490, J3590
|
|
ING-CC-0221
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Spevigo (spesolimab-sbzo)
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C9399, J3490, J3590
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Site of care updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0065
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Advate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
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Adynovate (factor vii)
|
J7207
|
|
ING-CC-0065
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Afstyla (antihemophilic factor (recombinant) single chain))
|
J7210
|
|
ING-CC-0065
|
Alphanate (antihemophilic factor viii)
|
J7186
|
|
ING-CC-0065
|
Eloctate (recombinant antihemophilic factor)
|
J7205
|
|
ING-CC-0065
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Esperoct (factor viii recombinant, glycopegylated)
|
J7204
|
|
ING-CC-0065
|
factor viii, anti-hemophilic factor (porcine)
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J7191
|
|
ING-CC-0065
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Hemlibra (emicizumab-kxwh)
|
J7170
|
|
ING-CC-0065
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Hemofil M ((factor viii) human plasma-derived)
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J7190
|
|
ING-CC-0065
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Humate-P (antihemophilic factor viii)
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J7187
|
|
ING-CC-0065
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Jivi (factor viii, recombinant, pegylated-aucl)
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J7208
|
|
ING-CC-0065
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Koate DVI ((factor viii) human plasma-derived)
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J7190
|
|
ING-CC-0065
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Kogenate-FS (factor viii (antihemophilic factor, recombinant))
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J7192
|
|
ING-CC-0065
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Kovaltry (factor viii (antihemophilic factor, recombinant))
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J7211
|
|
ING-CC-0065
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Novoeight (factor viii (antihemophilic factor, recombinant))
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J7182
|
|
ING-CC-0065
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Nuwiq (factor viii (antihemophilic factor, recombinant))
|
J7209
|
|
ING-CC-0065
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Obizur (antihemophilic factor viii (recombinant))
|
J7188
|
|
ING-CC-0065
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Recombinate (factor viii (antihemophilic factor, recombinant))
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J7192
|
|
ING-CC-0065
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Vonvendi (von willebrand factor)
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J7179
|
|
ING-CC-0065
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Wilate (antihemophilic factor viii)
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J7183
|
|
ING-CC-0065
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Xyntha (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0065
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Xyntha Solofus (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0148
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AlphaNine SD (coagulation factor ix (human))
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J7193
|
|
ING-CC-0148
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Alprolix (recombinant coagulation factor ix)
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J7201
|
|
ING-CC-0148
|
Benefix (factor ix recombinant)
|
J7195
|
|
ING-CC-0148
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Idelvion (factor ix)
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J7202
|
|
ING-CC-0148
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Ixinity (factor ix)
|
J7195
|
|
ING-CC-0148
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Mononine (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
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Profilnine SD (factor ix complex human)
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J7194
|
|
ING-CC-0148
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Rebinyn (glycopegylated)
|
J7203
|
|
ING-CC-0148
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Rixubis (factor ix recombinant)
|
J7200
|
|
ING-CC-0149
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Coagadex (factor x)
|
J7175
|
|
ING-CC-0149
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Corifact (factor xiii concentrate (human))
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J7180
|
|
ING-CC-0149
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Feiba (anti-inhibitor coagulant complex)
|
J7198
|
|
ING-CC-0149
|
Fibryga (human fibrinogen)
|
J7177
|
|
ING-CC-0149
|
NovoSeven RT (factor viia recombinant)
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J7189
|
|
ING-CC-0149
|
RiaSTAP (fibrinogen concentrate)
|
J7178
|
|
ING-CC-0149
|
Sevenfact (factor vlla recombinant)
|
J7212
|
|
ING-CC-0149
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Tretten (coagulation factor xiii a-subunit (recombinant))
|
J7181
|
Step therapy updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Clinical criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Fylnetra
|
J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Rolvedon
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Stimufend
|
C9399, J3490, J3590
|
|
ING-CC-0002
|
Preferred
|
Neulasta
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Neulasta OnPro
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
ING-CC-0002
|
Non-preferred
|
Nyvepria
|
Q5122
|
|
ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
This is a courtesy notice that there is a non-material change in the clinical criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).
Quantity limit updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0017
|
Xiaflex (collagenase clostridium histolyticum)
|
J0775
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0182
|
Feraheme (ferumoxytol)
|
Q0138
|
|
ING-CC-0182
|
Ferrlecit (ferric gluconate)
|
J2916
|
|
ING-CC-0182
|
Infed (iron dextran)
|
J1750
|
|
ING-CC-0182
|
Injectafer (ferric injection)
|
J1439
|
|
ING-CC-0182
|
Monoferric (ferric derisomaltose)
|
J1437
|
|
ING-CC-0182
|
Venofer (iron sucrose)
|
J1756
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
According to the American Medical Association (AMA) Current Procedural Terminology® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and
subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after December 1, 2022, Anthem Blue Cross and Blue Shield Healthcare Solutions will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the claims payment dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M code.
If you have questions on this program, contact your contract manager or Provider Experience representative.
Alcohol use disorders (AUD) often coexist with, contribute to, or result from many different psychiatric disorders. 1 Because AUD can mimic and complicate many mental health disorders, AUD leads to challenges in diagnoses for psychiatric complaints.
Heavy alcohol use directly affects brain function and may manifest as a broad range of psychiatric symptoms. Common mental health symptoms of AUD include depression and anxiety.
In addition, patients diagnosed with mental health disorders are more likely to use a high amount of mental health services, have difficulties decreasing alcohol consumption, and struggle with suicidal ideation or attempts.
Common co-occurring mental health conditions include depressive disorders, anxiety, schizophrenia, and bipolar disorders.
Depressive disorders:2
AUD and depressive disorders are among the most prevalent co-occuring disorders. Depressive disorders are the most common comorbid mental health conditions with AUD. People with AUD are 2 to 3 times more likely to have depression. People with alcohol dependence are more likely to have a depressive disorder than those with alcohol abuse.
Co-occurring AUD and depressive disorders disproportionately affect women, as these disorders are two times more likely to occur in women than in men. Racial and ethnic minorities also encounter systemic disadvantages. For instance, Black and Latino people are significantly less likely to receive integrated mental health and substance use treatment than other races and ethnicities.
Research suggests that AUD is equally as likely to precede depression as well as for depression to precede AUD. In addition, having one increases the risk of having the other. Though the etiology of these disorders is not fully known, studies have identified some evidence of genetic predisposition or dysfunction in reward and stress systems of the brain.
Anxiety:3
Up to half of patients receiving treatment for AUD meet the criteria for one or more anxiety disorders. Data shows that patients with anxiety disorders have poorer outcomes in treatment for alcohol use. Conventional treatment for anxiety (antidepressants and behavioral therapy) do not appear to reduce AUD. This suggests that co-occurring anxiety and AUD benefits from being treated separately but simultaneously.
In addition, patients with an anxiety disorder or AUD experience an increased risk in developing the other disorder. Trauma, chronic stress, and other inheritable traits are associated with the dysfunction in stress‑response systems present in AUD and anxiety disorders.
Schizophrenia:4
The prevalence of schizophrenia is about 1% of the population; however, patients with schizophrenia are at a three times greater risk for AUD. Between 25% to 36% of patients with schizophrenia meet the criteria for AUD. Schizophrenia has a strong genetic risk factor, and a large genome-wide study revealed a significant genetic correlation between schizophrenia and AUD.
There are several theories as to why AUD is so highly prevalent in patients with schizophrenia:
- A combination of neurobiological vulnerability (genetic risk) and environmental vulnerability (poverty, homelessness, trauma, etc.)
- The concept of self-medication, suggesting people with schizophrenia turn to alcohol for relief from their psychiatric symptoms
- Similar to depressive disorders, the hypothesis that both schizophrenia and AUD are related to a dysregulation of the reward system in the brain
Bipolar disorder:5
Bipolar disorder is the most likely psychiatric disorder to have a co‑occurring condition with a substance use disorder (SUD). Estimates for a lifetime co‑occurring bipolar disorder and AUD is between 40% to 70%. These co-occurring disorders are most common in women.
Bipolar disorder occurs in between 1.5% to 5% of the population. Like schizophrenia, bipolar disorder has a shared genetic predisposition with AUD. Heavy alcohol use worsens symptoms of bipolar disorder and can trigger episodes of mania and depression. Conversely, these episodes can lead to increased alcohol consumption. Treatment for bipolar disorder often assists in treatment for co‑occurring AUD. Mood stabilizers used to treat bipolar disorder have been shown to reduce alcohol cravings in patients with bipolar disorder.
Alcohol (and other substances) are likely triggers for the onset of bipolar disorders. In one study, substance use preceded 60% of first manic episodes.6 In juvenile cases, bipolar onset early in life is correlated with AUD development as an adult.
What if I need assistance?
If you need assistance connecting your patients to mental health or AUD treatment, contact Anthem Blue Cross and Blue Shield Healthcare Solutions Provider Services at 844-396-2330.
Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/nv/pages/medical-policies.aspx.
You can request a free copy of our UM criteria from Provider Services at 844-396-2330. Providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the number listed below. To access UM criteria online, go to https://mediproviders.anthem.com/nv/pages/medical-policies.aspx.
We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues. You can submit precertification requests by:
- Fax:
- Durable medical equipment (DME), physical therapy, occupational therapy, speech therapy, pain management, home care, home infusion requiring nursing services, insulin pumps, hyperbaric treatment, or wound care: 866-920-8362.
- All other inpatient and outpatient services: 800-964-3627.
- Pharmacy prior authorization, including home infusion injectables, continuous glucose monitoring equipment, and diabetic supplies: 844-490-4876.
- Phone: 844-396-2330.
- Pharmacy: 844-396-2330.
- Availity* Essentials: availity.com.
Have questions about utilization decisions or the UM process?
Call our Clinical team at 844-396-2330, Monday through Friday, from 8 a.m. to 5 p.m. PT.
Medicare Advantage
Effective for dates of service on and after October 1, 2022, updated step criteria for immunoglobulins found in Clinical Criteria document ING-CC-0003 has been implemented. The preferred product list is being expanded. Please refer to the Clinical Criteria page for more information.
Find Care, the doctor finder and transparency tool in the Anthem Blue Cross and Blue Shield (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website at www.anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetic order, and provider name.
Beginning January 1, 2023, or later, an additional sorting option will be available for members to search by provider performance called Personalized Match. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Provider pairings with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetic order, and provider name.
- You may review a copy of the Personalized Match methodology which has been posted on Availity* – our secure web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at availity.com.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to availity.com.
Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare Part B drugs
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C9399, J3490, J3590, J9999
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Opdualag (nivolumab and relatlimab-rmbw)
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C9096
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Releuko (filgrastim-ayow)
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A9699
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Pluvicto (lutetium lu 177 vipivotide tetraxetan)
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