 Provider News NevadaOctober 1, 2018 October 2018 Anthem Provider Newsletter - NVEffective 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. 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. Great news! Anthem, Inc. and our affiliates now use Availity as our designated EDI service. If you currently use a clearinghouse, billing company, or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.
Check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session. During this fast paced hour, learn how to:
- Understand Availity’s EDI Gateway and Clearinghouse workflow for 837, 270/271, 276/277, and 835 transactions.
- Use the Availity Portal to manage file transfers, set up EDI reporting preferences, manage your FTP account, and more.
- Enroll for and manage 835 ERA delivery with Availity.
- Access and navigate the Availity EDI Guide.
- and more…..
Upcoming Sessions
Currently scheduled upcoming sessions include:
- October 29, 2018, 1:00 p.m. – 2:00 p.m. ET
- November 7, 2018, 11:00 a.m. – 12:00 p.m. ET
Enroll
- Log in to the Availity Portal.
- Select Help and Training > Get Trained.
- In the Availity Learning Center (ALC) Catalog, select Sessions.
- Scroll Your Calendar to find and enroll for a live session.
Can’t make it?
We’ve got you covered with a recording of a previous live session. In the ALC, search the Catalog by keyword (song) and enroll for the on-demand option.
Need Help?
Email training@availity.com if you have issues enrolling for a live webinar. Anthem has partnered with Availity to operate and service the entry point for all EDI submissions to Anthem, otherwise known as the EDI Gateway.
Who is Availity?
Most of you know Availity as web portal or claims clearinghouse, but they are much more. Availity is also an intelligent EDI Gateway for multiple vendors and will be the EDI connection for all Anthem Inc. and its affiliates.
If you currently use a clearinghouse, billing company or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.
How are you submitting EDI transactions today?
- If you currently transmit your EDI Submissions using a clearinghouse or billing company, you should contact your clearinghouse to confirm your EDI submission path has not changed. If you are notified of any potential impacts with connectivity, workflow or financial, please know there are no cost submission options available with Availity.
- If you currently submit directly to Anthem and already have an Availity login for the portal, you can use that same login for your EDI services.
How can you directly transmit EDI submission to Availity?
Below are the different ways you can submit direct EDI transactions to Availity:
- Submit transaction files through FTP - If you work with a practice management system, health information system, or other automated system that supports an FTP connection, you can securely upload EDI transactions to the Availity FTP site where they are automatically picked up by Availity and submitted to Anthem.
- Submit transaction files through the Availity Portal - If you have batch files of EDI transactions that you need to process and you choose not to use the
Availity FTP site, you can manually upload the batch files through the Availity Portal.
- Submit transactions through manual data entry in the Availity Portal - The Availity Portal makes it easy to submit transactions, such as eligibility and benefits inquiries or claims, by entering data into our user-friendly web forms.
What are your next steps?
- We recommend that you register with Availity for your EDI transmissions and begin migrating your volume by the end of 2018. These include the 837, 835 and 27X (eligibility and claim status).
- Availity will be working directly with your clearinghouse, billing companies and your organization if you choose to submit directly - your organization.
We look forward to delivering a smooth transition to the Availity EDI Gateway.
If you have any questions please contact Availity Client Services at 1-800-Availity (1-800-282-4548) Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time. The Education and Reference Center (ERC) offers the Communication & Education section where you can find training materials, important policy information, commonly used forms and reference guides on Anthem’s proprietary tools. When you visit the ERC, you can efficiently navigate to all available electronic resources using only the Availity Portal.
The Communication & Education section, within the ERC, includes two new categories to help make it easier for you to find what you need: Payer Spaces Tools and Interactive Care Reviewer.
With an Availity log in you can easily view any new content added to the ERC. There is no additional role assignment needed.
Find the ERC on the Availity Portal under Payer Spaces │Anthem │Applications │Education and Reference Center. If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your Favorites. The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for non-grandfathered policies. The appropriate use of modifier 33 will reduce claim adjustments related to preventive services and your corresponding refunds to members.
Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.
Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.
The CPT® 2018 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”
In our ongoing efforts to encourage medical and behavioral health integration, Anthem continues to promote early identification and intervention of behavioral health issues through primary care. Anthem currently reimburses for screening and assessment for behavioral health and substance use through billing the following codes:
- G0396 /99408 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes
- G0397 / 99409 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes
- G0442 - Annual alcohol misuse screening, 15 minutes £ G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
- G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
- G0444 - Annual depression screening, 15 minutes
Anthem also supports behavioral counseling for specific chronic conditions while in the primary care office. These services include:
- G0446 - Annual, face-to-face intensive behavioral therapy for cardiovascular disease, 15 minutes
- G0447 - Face-to-face behavioral counseling for obesity, 15 minutes
- G0473 - Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes
In addition, Anthem reimburses for the psychiatric collaborative care codes; procedure codes 99492, 99493, 99494 are used to report these services. These codes are reportable by primary care for their collaboration with a qualified behavioral health provider, such as a Psychiatrist, Licensed Clinical Social Worker, etc.. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a BH specialist. The American Psychiatric Association (APA) has created a training program for primary care on the collaborative care model and the use of these codes. It can be found at APA Training Module. The Special Investigations Unit (SIU) is tasked to conduct investigations involving allegations of fraud, waste and abuse, to work with our providers to resolve billing practice issues in order to reduce or eliminate future payment issues, and, where appropriate, to recover overpayments.
As part of Anthem’s role to safeguard our members and provide relevant information to providers we are relaying the following recent Food and Drug Administration (FDA) Warning Letters:
Estring - On June 19, 2018 the Food and Drug Administration issued a letter of warning to Pfizer for "false or misleading" promotional materials related to ESTRING® (estradiol vaginal ring). According to the FDA the posted “… video is especially concerning from a public health perspective because it fails to include any risk information about Estring, which is a drug that bears a boxed warning due to several serious, life-threatening risks, including endometrial cancer, breast cancer, and cardiovascular disorders, as well as numerous contraindications and warnings. The video thus creates a misleading impression about the safety and efficacy of Estring”.
Xtampza – On February 9, 2018 the Food and Drug Administration issued a letter of warning to Collegium Pharmaceuticals for publicly providing false or misleading representations regarding Xtampza (oxycodone) ER because it “fails to adequately communicate information about the serious risks associated with Xtampza ER use”.
Further details regarding these Warning Letters from the FDA can be obtained at:
Estring:
https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmaceuticalCompanies/UCM612143.pdf
Xtampza:
https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmaceuticalCompanies/UCM597584.pdf Anthem accepts electronic medication pre-certification requests for commercial health plans. This feature reduces processing time and helps determine coverage quicker. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.
Electronic pre-certification (ePA) offers many benefits:
- More efficient review process
- Ability to identify if a pre-certification is required
- Able to see consolidated view of ePA submissions in real time
- Faster turnaround times
- A renewal program that allows for improved continuity of care for members with maintenance medications
- Pre-certification are preloaded for the provider before the expiration date.
Providers can submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.
While ePA helps streamline the pre-certification process, providers can also initiate a new pre-certification request by fax or phone. Please note, the contact numbers for the following plans have changed effective November 4, 2018.
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Nevada on the exchange
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844-471-7941
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New phone number
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Nevada on the exchange
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844-471-7941
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833-293-0660
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Nevada off the exchange
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844-534-9054
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833-293-0659
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For questions, please contact the provider service number on the member ID card.
The Anthem provider claim payment dispute process consists of two steps.
- Claim payment reconsideration: This is the first step in the Anthem provider payment dispute process. The reconsideration represents your initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step.
- Claim payment appeal: This is the second step in the Anthem provider payment dispute process. If you disagree with the outcome of the reconsideration, you may request an additional review as a claim payment appeal.
Currently, providers can submit claim payment disputes through our Claim Action Request form (for a reconsideration), or through the Provider Dispute Resolution form (for an appeal).
Beginning in early November we will start a limited launch with designated providers. In early December all providers will have the ability to submit claim disputes electronically through the Availity Portal (our secure web-based provider tool). In addition, the provider manual will be updated in the near future to outline this new electronic process.
For providers, this means an enhanced experience when:
- Filing a claim payment dispute.
- Sending supporting documentation.
- Checking the status of your claim payment dispute.
- Viewing your claim payment dispute history.
For step-by-step instructions to submit a dispute:
- Log into Availity at availity.com
- Select Help & Training | Find Help
- Under Contents, select Overpayments and Appeals
- Select Dispute a Claim
Once a claim payment dispute is submitted through Availity, Anthem will review the request and communicate an outcome through the Availity Portal back to the Availity user. If the provider still disagrees with the reconsideration, the provider can then choose to appeal the claim payment.
Once the claim payment dispute is submitted for a second time, the decision is final, and may not be submitted again.
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained
- Select Sessions and go to Your Calendar to locate a webinar
- Select View Course and then select Enroll
The Availity Learning Center will email you with instructions to attend.
Scheduled live webinars:
- October 4, 2018, 2-3 p.m. EST
- October 24, 2018, 2-3 p.m. EST
- November 1, 2018, 2-3 p.m. EST
- November 6, 2018, 2-3 p.m. EST
- November 27, 2018, 2–3 p.m. EST
- December 6, 2018, 2–3 p.m. EST
- December 13, 2018, 2–3 p.m. EST
Continuing to build on the initial launch of the new public provider pages, Anthem recently released a brand new, redesigned landing page for Provider Resources. The most recent release also includes a new Communications page with a clear and concise access point for Newsletters and eUpdates, as pictured here.
This October, anthem.com will be introducing exciting changes to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for manuals and an improved, streamlined experience for Reimbursement Policies.
We will continue to keep you informed on upcoming changes to the public provider site as we progress toward streamlining our web platform and other business processes. Please join us for one of our upcoming provider seminars in Nevada - registration closes October 5th! The sessions include important updates and information about doing business with us. Topics include:
- Product overview for 2019
- Medicaid Updates
- Member ID card changes
- Risk Adjustment program overview
- New Provider newsletter/communication template
- Anthem.com Provider website enhancements
- Availity Portal enhancements
- Plus more!
If you haven't registered already, please save your spot today. For locations and dates, see our Provider Seminar Invitation.
Online registration that’s quick and easy!
Our registration process is available online for both our “In-person” meetings, as well as “webinars”.
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.
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 your calendar.
Register using one of the following links:
* Note: We use the same registration software for In-Person sessions as we use for Webinars. The calendar appointment for In-Person meetings will include the location for which you've registered. Please disregard any text referring to the meeting being available online.
CMS average sales price (ASP) forth quarter fee schedule with an effective date of October 1, 2018 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on November 1, 2018. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/. On the date the new edit becomes effective, Clear Claim Connection, our web-based editing tool, will be updated to incorporate the new editing rules outlined above and will include an interface that will allow you to view the clinical rationale for the edit when you enter claim scenarios. If you have not used Clear Claim Connection previously, we would like to take this opportunity to encourage you to access this user-friendly tool to explore the ClaimsXten edits. Clear Claim Connection is located on the Availity Portal. Log into Availity.com. Once logged in, select Payer Spaces, and choose the Anthem icon. Under Applications, select Clear Claim Connection. In our Assistant Surgery Services Coding Chart dated June 15, 2018, we are adding procedure codes 15733, 19294, 20939, 31241, 31253, 31257, 31259, 31298, 36465, 36466, 36482, 36483, 38222, 55874, 0479T, 0483T, 0484T, C9738, C9748, G0516, G0517, G0518, (effective January 1, 2018), and C9749 (effective April 1, 2018) to our “Assistant Surgeon Not Allowed” code list to document our edit that these codes are not eligible for reimbursement when reported by an assistant surgeon. Please note that we are deleting code 44360 from the list as this code does allow an assistant surgeon; we are also removing deleted codes 44347, 44349, and 44350 from the “Assistant Surgeon Not Allowed” code list.
For more information, view Reimbursement Policy – Professional: Assistant Surgery Services/Code List Extension for Community Healthcare Outcomes (ECHO)
Opioid overdose rates continue to rise. With the support of MAT ECHO, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website.
Benefits of participating include:
- Addiction treatment training.
- Free continuing education credits.
- Opportunity to receive expert input on your (de-identified) patient cases.
- Access to a virtual learning community for treatment guidelines, tools and patient resources.
- Opportunity to ask questions and get a variety of support from specialists.
Quality Medication-Assisted Therapy (MAT)
To help ensure members have access to comprehensive evidence-based care, Anthem is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.
When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with buprenorphine or, in some plans, methadone maintenance treatment in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.
For more information
For more information about best practices for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.
You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs. For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacyinformation. The commercial drug list is posted to the web site quarterly (the first of the month for January, April, July and October).
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. Effective January 1, 2018, AllianceRX Walgreens Prime is the new specialty pharmacy program for the Federal Employee Program. You can view the 2018 Specialty Drug List or call us at 1-888-346-3731 for more information. Providers can access real-time, patient-specific prescription drug benefit information at the point of care. It is part of the e-prescribing process, and is located within a provider’s electronic medical record (EMR) system.
This functionality helps providers determine prescription coverage quicker by sharing information about patient drug cost, formulary, and coverage alerts such as prior authorization to sending a prescription to the pharmacy. This information can help providers proactively identify barriers to medication compliance. For example, if a medication is too costly for the member, alternatives can be discussed prior to the patient leaving the provider’s office.
Providers can find the following patient-specific prescription benefit information with their EMR:
- Formulary status of selected medication
- Pricing of medication at a retail and mail order pharmacy
- Formulary alternatives
- Coverage alerts, including prior authorization and step therapy
Providers should contact their IT department or EMR system with questions regarding access to real-time prescription drug benefit functionality. Upgrades to EMR software may be required. 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.
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 March 22, 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).
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Publish date
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Medical Policy number
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Medical Policy title
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New or revised
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3/29/2018
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MED.00120
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Voretigene neparvovec-rzyl (Luxturna™)
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New
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4/25/2018
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SURG.00151
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Balloon Dilation of Eustachian Tube
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New
|
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4/25/2018
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DME.00009
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Vacuum-Assisted Wound Therapy in the Outpatient Setting
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Revised
|
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3/29/2018
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GENE.00028
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Genetic Testing for Colorectal Cancer Susceptibility
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Revised
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4/25/2018
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RAD.00029
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CT Colonography (Virtual Colonoscopy) for Colorectal Cancer
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Revised
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4/25/2018
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SURG.00033
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Cardioverter Defibrillators
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Revised
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4/25/2018
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SURG.00098
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Mechanical Embolectomy for Treatment of Acute Stroke
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Revised
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4/25/2018
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SURG.00121
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Transcatheter Heart Valve Procedures
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Revised
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Clinical UM Guidelines
On March 22, 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.
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Publish date
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Clinical UM Guideline number
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Clinical UM Guideline title
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New or revised
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6/28/2018
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CG-BEH-15
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Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
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New
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6/22/2018
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CG-DRUG-89
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Implantable and Extended-Release Buprenorphine-Containing Products
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New
|
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6/28/2018
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CG-DRUG-90
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Intravitreal Treatment for Retinal Vascular Conditions
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New
|
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6/28/2018
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CG-DRUG-91
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Intravitreal Corticosteroid Implants
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New
|
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6/28/2018
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CG-DRUG-92
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Alpha-1 Proteinase Inhibitor Therapy
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New
|
|
6/28/2018
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CG-DRUG-93
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Sarilumab (Kevzara®)
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New
|
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6/28/2018
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CG-LAB-13
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Skin Nerve Fiber Density Testing
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New
|
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6/28/2018
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CG-MED-69
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Inhaled Nitric Oxide
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New
|
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6/28/2018
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CG-MED-70
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Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
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New
|
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6/28/2018
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CG-SURG-73
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Balloon Sinus Ostial Dilation
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New
|
|
6/28/2018
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CG-SURG-74
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Total Ankle Replacement
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New
|
|
6/28/2018
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CG-SURG-75
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Transanal Endoscopic Microsurgical Excision of Rectal Lesions
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New
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6/28/2018
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CG-THER-RAD-07
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Intravascular Brachytherapy (Coronary and Noncoronary)
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New
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4/25/2018
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CG-SURG-31
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Treatment of Keloids and Scar Revision
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Revised
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4/25/2018
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CG-SURG-49
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Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
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Revised
|
ANVPEC-0706-18 July 2018 In our efforts to improve pregnancy outcomes, including the prevention of preterm birth, Anthem Blue Cross and Blue Shield Healthcare Solutions previously communicated our endorsement of the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) guidelines on cervical length (CL) screening and progesterone treatment.
We continue to encourage you to obtain a CL measurement with your patient’s routine prenatal anatomic evaluation ultrasound. For claims submitted on or after January 1, 2019, if a vaginal approach is necessary in addition to an abdominal scan to obtain this measurement, the transvaginal ultrasound will be considered for a multiple procedure reduction.
When a routine anatomic evaluation ultrasound (76801, 76802, 76805, 76810) and a transvaginal ultrasound (76817) are billed on the same day by the same provider, the transvaginal ultrasound is considered a part of the multiple procedure payment reduction policy and will be paid at 50% of the applicable fee schedule, and the complete procedure will be paid at the full applicable fee schedule.
If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services toll free at 1-844-396-2330.
Thank you for being a valued provider.
ANVPEC-0672-18 September 2018
Obesity is a serious issue in the United States. The obesity rate is rising. Obesity has significant health consequences, contributing to increased incidence of several diseases, including metabolic syndrome, high blood pressure, diabetes, heart disease, high blood cholesterol, sleep disorders and cancers.
For detail information on obesity HEDIS® measurements and coding, please view the full update on our provider website.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
ANV-NL-0036-18 September 2018 Extension for Community Health Care Outcomes (ECHO)
People are dying of opioid addiction. With the medication assisted treatment, you can help save lives! Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website at https://echo.unm.edu.
Benefits of participating include:
- Addiction treatment training.
- Free continuing education credits.
- Opportunity to receive expert input on your (de-identified) patient cases.
- Access to a virtual learning community for treatment guidelines, tools and patient resources.
- Opportunity to ask questions and get a variety of support from specialists.
Quality Medication-Assisted Therapy (MAT)
To help ensure members have access to comprehensive evidence-based care, Anthem is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.
When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with naltrexone, buprenorphine or, in some plans, methadone in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.
For more information
For more information about what is considered best practice for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.
You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.
ANV-NL-0035-18 August 2018 No action is required for providers already registered for electronic funds transfers (EFTs) and electronic remittance advices (ERAs).
Effective December 1, 2018, our provider disbursement processes are changing. These changes include the following:
- New EFT enrollment: Go to EnrollHub™, a Council for Affordable Quality Healthcare (CAQH) Solutions™ enrollment tool.
- New ERA-only enrollment and change management for existing ERA-only enrollments: These will be managed through Availity. Go to https://www.availity.com and select Enrollments Center in the My Account Dashboard on the home page. Select ERA Enrollment in the Multi-Payer Enrollments section. Then, simply follow the wizard and submit. After submitting, you willl be notified by email that enrollment is complete and start receiving 835s through Availity.
- Change Healthcare and PaySpan will no longer be used for EFT/ERA enrollment.
- Providers now have access to Explanation of Payment letters through our secure self-service provider website.
These enhancements offer providers streamlined reimbursement registration tools.
The following chart summarizes information about the new processes to enroll in EFT or ERA or to update EFT and ERA transaction information after December 1, 2018.
Process to enroll or updated electronic transactions after December 1, 2108
Is registration required?
Providers are not obligated to register for either EFT or ERA and will continue to receive a paper check and remittance advice.
Is there a cost to providers for the changes to the EFT and ERA?
There is no cost to providers from Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem). Providers should inquire with trading partners and other vendors they work with to understand additional steps or any changes to services.
Information and changes to expect
- Medicaid claims are identified in the Claim Filing Indicator Code (CLP06 segment) on the ERA/835 as MC.
- Effective December 1, 2018, we will discontinue the email notification providers currently receive when an EFT and ERA is issued.
- The PDF versions of paper remittances are available on the provider self-service website. Both provider and clearinghouse 835s continue to be received through the EDI process. Aside from how providers access remits, this process remains the same.
- More information about retrieving copies of remittance advices is available online. To access our tutorial, Remittance Inquiry Process Guide, go to our provider website and select the Tutorials drop-down menu under Provider Documents & Resources.
- Starting in 2018, more claim payments and remittance advices issued by Anthem will be made on a weekly basis to providers. Additionally, non-Federal Employee Program payments under $5 will be held for a maximum of 14 days to allow additional claims to combine to increase the overall payment amount.
- This change will ensure efficiency and consistency between professional and facility claim payments.
- If you are a provider who receives paper claim checks or EFT payments from Anthem on a daily basis, you will be able to schedule posting on a weekly cycle after this change.
- The Automated Clearing House batch header is changing. The payee name that appears on the EFT statement is changing and will be easily identifiable. This change does not impact payment to you in any way. You will now see Anthem NV5C.
How do I access historical ERAs from Change Healthcare and PaySpan?
We are in the process of migrating all historical remittance advices to our secure self-service provider website. We will notify you when the migration is complete. Please continue to use Change Healthcare and PaySpan until that time.
What if I need assistance?
If you have questions about this communication, received this fax in error or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-844-396-2330.
ANV-NL-0034-18 July 2018 Effective October 1, 2018, PA requirements will change for injectable/infusible drugs mepolizumab (Nucala®) and reslizumab (Cinqair®). 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:
- Mepolizumab (Nucala) — injection, 1 mg (J2182)
- Reslizumab (Cinqair) — injection, 1 mg (J2786)
To request PA, you may use one of the following methods:
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.
ANV-NL-0032-18 August 2018 Effective October 1, 2018, prior authorization (PA) requirements will change for injectable drug Cabazitaxel (Jevtana) 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:
- Cabazitaxel (Jevtana) — injection, 1 mg (J9043)
To request PA, you may use one of the following methods:
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool (https://www.availity.com). Contracted and noncontracted providers who are unable to access Availity may call us at 1-844-396-2330 for PA requirements.
ANV-NL-0030-18 August 2018 Effective September 1, 2018, Anthem Blue Cross and Blue Shield Healthcare Solutions prior authorization (PA) requirements will change for the injectable drug Darzalex (daratumumab) for Medicaid members. 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:
- J9145 — Injection, Darzalex (daratumumab), 10 mg
To request PA, you may use one of the following methods:
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool (https://www.availity.com). Contracted and noncontracted providers who are unable to access Availity may call us at 1-844-396-2330 for PA requirements.
ANV-NL-0027-18 July 2018 All programs require prior authorization (PA) for all covered specialty medications, where allowable by state. The scope of this notice will include both professional and facility requests for Medicaid business.
Specialty medications that are reported with not otherwise classified (NOC) designation codes and
C-codes may also require PA before services are provided.
Regardless of whether PA is required, all services must be medically necessary to be covered. Even if PA is not required, to avoid a claim denial based on medical necessity, Anthem Blue Cross and
Blue Shield Healthcare Solutions (Anthem) encourages providers to review our medical necessity criteria prior to rendering nonemergent services. Medical necessity criteria can be accessed by visiting https://mediproviders.anthem.com/nv to view the most current Medical Policies and Clinical Utilization Management Guidelines.
If no specific policy is available, the medical necessity review of a drug may be conducted using Medical Policy ADMIN.00006: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management Guideline and/or Clinical Utilization Management Guideline CG-DRUG-01: Off-Label Drug and Approved Orphan Drug Use.
Clinical review of specialty medications is in addition to services currently requiring PA. Providers are responsible for verifying eligibility and benefits for Anthem members before providing services. We recommend providers visit https://mediproviders.anthem.com/nv to review the list of services and service categories currently requiring PA, with a reminder that the list of services requiring PA will be updated as needed. For clarification regarding whether a specific code or service requires PA, call the number listed below. Except in an emergency, failure to obtain PA may result in denial of reimbursement.
Again, please be reminded that the list of services requiring PA will be updated as needed.
Requesting PA
To request PA, report a medical admission or for questions regarding PA, providers may use one of the following methods:
Providers are strongly encouraged to revisit the Government Business Division Reimbursement Policy Unlisted or Miscellaneous Codes policy, which states NOC codes must be submitted with the correct national drug code (NDC) for proper claim payment. If the required NDC data elements are missing or invalid for the procedure code on a claim line, the claim will be denied.
ANV-NL-0025-18 July 2018 Per guidance established by the Comprehensive Addiction and Recovery Act of 2016, the Centers for Medicare & Medicaid Services has established provisions to develop a pharmacy and prescriber home program for opioid medications. Beginning January 1, 2019 Anthem will work with beneficiaries and providers to help to reduce the risk of opioid dependency by streamlining access to opioid medications. If a beneficiary is exhibiting at-risk opioid medication utilization, the plan sponsor will work with the beneficiary and provider to select a pharmacy home and prescriber home for the beneficiary’s opioid medications. At risk is defined by CMS as
- Cumulative Morphine Milligram Equivalent (MME) > 90mg per day
- Opioid prescribers > than three and opioid dispensing pharmacies > than three
- Or Opioid prescribers > than five regardless the number of pharmacies
- Cancer, LTC and Hospice are exempt
- Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.
- Plan sponsors will request agreement from the provider selected as the home.
- At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.
- Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.
- Beneficiaries retain the right to request a coverage determination and may choose to change their Home pharmacy or prescriber at any time.
Effective January 1, 2019, Anthem will transition its Medicare back pain management and cardiology programs from OrthoNet LLC to AIM Specialty Health® (AIM), a specialty health benefits company. Anthem has an existing relationship with AIM in the administration of other medical management programs. Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider. The AIM Genetic Testing program requires ordering providers to request medical necessity review of all genetic testing services for individual Medicare Advantage members. Requesting this prior authorization will help ensure that the lab receives timely and accurate payment for these services.
Please submit genetic testing prior authorization requests to AIM through one of the following ways:
- Access AIM 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 at 800-714-0040, Monday–Friday, 7 a.m.–7p.m. CT.
For further questions regarding prior authorization requirements, please contact the Provider Services number on the back of your patient’s ID card. |
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