As we continue our efforts to help ensure our members enrolled in Affordable Care Act (ACA) compliant plans have their chronic conditions assessed and documented each year, Anthem Blue Cross and Blue Shield (Anthem) is engaging Matrix to help encourage members – on our behalf – to schedule a mobile health clinic assessment.  A vendor, Matrix operates the largest fleet of mobile medical centers nationwide and has conducted more than 1,000,000 patient assessments since 1998 – providing convenient access to comprehensive health assessments. 

The mobile clinic provides members with additional options to help them close any gaps in care that they may have.  In late July, Matrix began reaching out to members on our behalf by letter and phone. Our outreach efforts will continue until the end of this year.

Matrix works with hospitals and health plans like Anthem to deliver preventive health testing to the communities Matrix serves.  Each mobile clinic has a reception area and private screening rooms.  Matrix also helps members with scheduling follow-up appointments with their PCPs at the end of the assessments and forwards the PCPs a copy of any results from the health assessment.

Matrix In-Home Assessments

Matrix will perform in-home assessments where possible. The in-home assessments offer a board-certified nurse practitioner (NP) to come to a member’s home to provide a general exam, suggestions for important screenings or other tests, a full review of the medicines they take, answers to health-related questions and a personal health summary detailing their health information.  A copy of the assessment will be sent to members’ PCPs to ensure continuity of care.

The overall goals of the mobile clinic program and the in-home program are to provide convenient, comprehensive appointments that are designed to complement the care provided by our network of physicians.  These mobile clinic or in-home visits do not replace any active treatment plans members currently have with their physicians and are not considered wellness visits or a substitute for members’ annual physical examinations. 

We’re including information about the program in this edition of Provider News should patients contact you about the program.  Please refer members directly to Matrix if they have questions or need more information:

• Mobile Bus: 888-822-3247
• In-Home: 855-403-0967

2019 Retrospective Chart Request

Retrospective medical chart collection begins in November and it is the most significant and largest volume of our requests.  We appreciate your collaboration as we work through the requests and submit to your medical records department in a timely manner.

Electronic options for chart collections

We have 4 electronic options for chart collections to choose from: 

1. Remote/Direct Anthem Access
2. Electronic Medical Record (EMR) Interoperability with 4 EMR systems
3. Inovalon virtual visit or onsite
4. Secure FTP

Submitting medical charts can be time consuming for your staff.  Utilizing an electronic option can alleviate the constraints on your staff’s resources and time. 

The most efficient electronic option is to allow the Anthem medical coder team to have direct connection access to your EMR system (Option 1), so that we may retrieve the records ourselves.  Our team has collaborated with several Providers and Facilities to have direct access to their EMR systems to collect the charts.  This allows for no vendor interventions and fewer handoffs of the records.  To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI. 

If you are interested in any of these electronic options, or you would like to grant Anthem medical coders direct access to your EMR system, please contact Socorro.Carrasco@anthem.com, our Commercial Risk Adjustment Representative who supports your area.

Thank you for your continued efforts with our CRA Program, and your help in expediting chart collection requests.

• A new Contact Us page that gives providers easy access to important contact information
• A redesigned Medicare Advantage page with an improved, effortless user experience
• Clear and easy access to training and education materials through a new Training and Education page
• A new Enhanced Personal Health Care (EPHC) page that provides a more prominent and easier access to information that communicates Anthem’s role in transforming health care. (EPHC is a program designed to advance and support a patient-centered approach to care delivery.)

Below is a preview of the new Contact Us and Medicare Advantage page:  

Category: Medicare

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

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

To view a guideline, visit the provider website at www.anthem.com/medicareprovider.

Notes/updates

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• * DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
• * LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
• * LAB.00033 — clarified investigational and not medically necessary statement to include 4Kscore and AR-V7
• * OR-PR.00003:
  • Clarified medically necessary position statement criteria 2 through 4
  • Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered investigational and not medically necessary for all indications
• * SURG.00011:
  • Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
  • Added new products to investigational and not medically necessary statement
• * SURG.00045:
  • Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement
  • Revised title
• * SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications
• The following AIM Specialty Health® updates took effect on September 28, 2019:
  • Advanced imaging:
    • Imaging of the heart
    • Oncologic imaging
    • Vascular imaging
  • Proton beam therapy
  • Rehabilitative therapies — physical therapy, occupational therapy and speech therapy (new)

Medical Policies

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

Clinical UM Guidelines

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the Medical Operations Committee for Medicare Advantage members on July 5, 2019.

ABSCRNU-0061-19 August 2019          503273MUPENMUB

Category: Medicaid

Please continue to check Medicaid Provider Communications & Updates at anthem.com/mediproviders for the latest Medicaid information, including:

• Medical Policies and Clinical Utilization Management Guidelines update

Category: Medicaid

The upgrade to the 23rd edition of the MCG Care Guidelines for Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) has changed from May 24, 2019, to October 18, 2019. In addition, Anthem has customized some of the MCG Criteria.

Customizations to the 23rd edition of the MCG Care Guidelines:

Effective October 18, 2019, the following customizations will be implemented:

• Left Atrial Appendage Closure, Percutaneous (W0157) — customized to refer to SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  
  
• Spine, Scoliosis, Posterior Instrumentation, Pediatric (W0156) — customized to refer to Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines

Effective November 1, 2019, customizations will be implanted for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria and guidance on the following:

• Clinical indications for admission; examples will also be added for:
  • o Aggressive hydration needs that cannot be managed in an infusion center.
  • o Prolonged marrow suppression.
• Regimens that cannot be managed outpatient; examples will also be added.

Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition (Publish date November 1, 2019).

For questions, contact Provider Services at 1-844-396-2330.

ANV-NU-0071-19 August 2019

Category: Medicaid

Effective October 1, 2019, prior authorization (PA) requirements will change for hyperbaric oxygen and supervision of hyperbaric oxygen therapy 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:

• G0277 — Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval
• 99183 — Physician attendance and supervision of hyperbaric oxygen therapy, per session

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. Detailed PA requirements are available to contracted providers by accessing the Precertification Lookup Tool at https://www.availity.com via

https://mediproviders.anthem.com/nv. Contracted and noncontracted providers who are unable to access the Availity Portal can call Provider Services at 1-844-396-2330.

ANV-NU-0065-19 August 2019

Category: Medicaid

Effective December 1, 2019, prior authorization (PA) requirements are changing for the codes listed below. The listed codes will require PA by Anthem Blue Cross and Blue Shield Healthcare Solutions for Nevada 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 are being added to the following:

• Lower extremity prosthesis — shank foot system with vertical loading pylon (L5987)
• Gait trainer, pediatric size — anterior support, includes all accessories and components (E8002)
• Wheelchair, pediatric size — tilt-in-space, folding, adjustable, without seating system (E1234)
• Wheelchair, pediatric size — tilt-in-space, rigid, adjustable, without seating system (E1233)
• Transport chair, pediatric size (E1037)
• Multi-positional patient transfer system with integrated seat, operated by care giver (E1035)
• Wheelchair accessory — ventilator tray, gimbaled (E1030)
• Water circulating heat pad with pump (E0217)

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

Category: Medicaid

Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) offers pregnant women several services and benefits through the New Baby, New LifeSM program. Anthem provides education, support, resources and incentives to members throughout the prenatal and postpartum period. Our goal is to ensure all pregnant members are identified early in their pregnancies so that they can take full advantage of these services.

We are working with Availity, the vendor supporting the Benefit Look-Up Tool you may currently use in your OB office, to get information about newly identified pregnant women. This new process, including the HEDIS® Maternity Attestation form, helps connect members to additional benefits as soon as possible using a few simple steps.

How it works

When an Anthem member of childbearing age visits the OB office, the office associate is prompted to ask the question “Is the member pregnant?” during the eligibility and benefits inquiry process. If the response is yes, the system asks about the due date, and a HEDIS Maternity Attestation form is generated for the OB office to complete. On this electronic form, providers are asked to provide other relevant information including the date of the first prenatal care visit, delivery date and postpartum visit date.

This new, user-friendly workflow generates timely information that aids members, providers and Anthem in improving birth outcomes with early intervention.

We are working hard to support providers throughout Nevada in receiving necessary training for this new workflow. If you have specific questions regarding the new Availity maternity attestation process, please feel free to reach out to Provider Services at 1-844-396-2330.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

Category: Medicare

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

• Medical Policies and Clinical Utilization Management Guidelines update
• Clinical Laboratory Improvement Amendments for Anthem Blue Cross and Blue Shield
• Lowering health risks with no-cost statins
• Assisting your patients in managing the Donut Hole
• Prior authorization requirements for continuous positive airway pressure supplies

Category: Medicare

The upgrade to the 23rd edition of the MCG Care Guidelines for Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) has changed from May 24, 2019, to October 18, 2019. In addition, Anthem has customized some of the MCG Criteria.

Customizations to the 23rd edition of the MCG Care Guidelines:

Effective October 18, 2019, the following customizations will be implemented:

• Left Atrial Appendage Closure, Percutaneous (W0157) — customized to refer to SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  
  
• Spine, Scoliosis, Posterior Instrumentation, Pediatric (W0156) — customized to refer to Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines

Effective November 1, 2019, customizations will be implanted for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria and guidance on the following:

• Clinical indications for admission; examples will also be added for:
  • Aggressive hydration needs that cannot be managed in an infusion center.
  • Prolonged marrow suppression.
• Regimens that cannot be managed outpatient; examples will also be added.

Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition (Publish date November 1, 2019).

For questions, contact Provider Services at 1-844-396-2330.

Category: Medicare

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem Blue Cross and Blue Shield for Medicare Advantage 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 the following codes:

• 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
• 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
• 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
• 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
• 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
• 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
• 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
• 33271 — Insertion of subcutaneous implantable defibrillator electrode
• 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
• 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X)
• 81219 — CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9 
• 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)
• 81302 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis
• 81303 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant
• 81304 —  MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants 
• 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81400 — Molecular pathology procedure, Level 1 (e.g., identification of single germline variant e.g., SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (e.g., medium chain acyl dehydrogenase deficiency)
• 81401 — Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (e.g., acquired imatinib resistance)
• 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81407 — Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (e.g., generalized epilepsy with febrile seizures), full gene sequence
• 81408 — Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (e.g., Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (e.g., neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (e.g., malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (e.g., von Willebrand disease types 1 and 3), full gene sequence
• 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
• C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
• C9043 — Injection, levoleucovorin, 1 mg
• C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
• D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
• D9920 — or management, by report
• J9999 — Not otherwise classified, antineoplastic drugs
• S3850 — Genetic testing for sickle cell anemia

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

• Web: https://www.Availity.com
• Phone: Call the Provider Services number on the back of the member’s ID card for PA requirements.

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call the Provider Services number on the back of the member’s ID card for PA requirements.

ABSCRNU-0052-19 August 2019          503100MUPENMUB

Category: Medicare

On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

ABSCRNU-0050-19 August 2019          502142MUPENMUB

Category: Medicare

On January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by Anthem will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests, call 1-833-293-0661.

ABSCRNU-0065-19 August 2019                                  503236MUPENMUB

Category: Medicare

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment guidelines. Information for each training is outlined below. The Medicare Risk Adjustment Regulatory Compliance team developed the following two provider trainings. This update outlines the training series:

Medicare risk adjustment and documentation guidance (general)

When – offered the first Wednesday of each month from December 5, 2018, to November 6, 2019 at 1 to 2 p.m. Eastern time.

Learning objective – This training will provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.

Credit – This activity has been reviewed and is acceptable for up to one prescribed credit by the American Academy of Family Physicians.

If you are interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

https://antheminc.adobeconnect.com/admin/show-event-catalog?folder-id=38826374.

Medicare risk adjustment, documentation and coding guidance (condition specific)

When – offered on the fourth Wednesday of every other month from January 23, 2019 to November 27, 2019 from noon to 1 p.m. Eastern time.

Learning objective – This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

Credit – This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians.

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

1. Red flag HCCs, part one – Register for recording of live session.
   
   Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration.
   
   https://antheminc.cosocloud.com/e4i5k4h7cf3j/event/registration.html.
   
   
2. Red Flag HCCs, part two – Register for recording of live session. 
   
   Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration.
   
   https://antheminc.cosocloud.com/enfndbyedd5g/event/event_info.html.
   
   
3. Opioids and more: substance abuse and dependence – Recording will play upon registration.
   
   https://antheminc.cosocloud.com/ekx3tooh22f7/event/registration.html.
   
   
4. Acute, chronic and status conditions – Recording will play upon registration.
   
   https://antheminc.cosocloud.com/eeq7am1fht49/event/registration.html.
   
   
5. Diabetes mellitus and other metabolic disorders – September 25, 2019
   
   https://antheminc.cosocloud.com/e9l4sxzbd2lq/event/registration.html.
   
   
6. Behavioral health – November 27, 2019
   
   https://antheminc.cosocloud.com/eatxsocnqf6h/event/registration.html.

ABSCRNU-0060-19 August 2019          502690MUPENMUB