As a reminder, Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (Anthem) have products called Guided Access HMO. We would like to share information regarding these plans to help ensure our providers have as much information as possible to assist in servicing members with one of these plans.

 

Guided Access HMO plans may be accessing a different network depending on the Health Benefit plan option.

• Large Group/Small Group members will utilize the HMO Nevada network
• Individual Exchange members will utilize the Pathway X HMO network

 

Referral requirements

Guided Access HMO plans both require a Primary Medical Group selection and Primary Care Physician (PCP) referral to specialists.  Submit referral requests should through Availity via the Interactive Care Reviewer (ICR) online referral tool.

 

Sample Guided Access HMO ID card

Please note the ID cards below are just samples, and do not include actual member information such as copays. That information will be included when the ID cards are generated and sent to members prior to the effective date

Summary of Information

 

Additional Details:

Contact your local Anthem network consultant for additional details regarding:

• Operational Procedures
• Referrals for Guided Access HMO
• Submit a Referral via Interactive Care Reviewer (ICR).

Anthem is dedicated to providing excellent customer service for Guided Access HMO members and their providers. We look forward to building a successful relationship. We appreciate this opportunity to assist you.

 

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Routinely, the Centers for Medicare & Medicaid Services (CMS) issue revisions to the average sales price (ASP) fee schedules regarding drug pricing.  To that end, CMS is supplying the fourth quarter fee schedule with an effective date of October 1, 2021.  This will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on November 1, 2021. To view the ASP fee schedule, please visit the CMS website at: https://www.cms.gov/medicare/medicare-fee-for-service-part-b-drugs/mcrpartbdrugavgsalespricecms.gov/medicare/medicare-fee-for-service-part-b-drugs/mcrpartbdrugavgsalesprice.

 

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If you missed our live continuing medical education (CME) webinars, you can still register for the recorded webinars and earn CME credits. Join our CME webinar series and learn best practices to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs performance.

 

Program objectives:

• Learn strategies to help you and your care team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.

 

Attendees will receive one CME credit upon answering required questions at the conclusion of each webinar.

 

REGISTER HERE for our upcoming live and on-demand clinical quality webinars.          

 

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In the coming months, we will be enhancing your ability to search, review and download a copy of the remittance advice on Availity when there is no associated payment. For remittance advices with payments, you may continue to search with the check/EFT number.

 

What’s changing?

1. Non-payment number display in the Check Number and Check/EFT Number fields:

• Current - Today, there are two sets of numbers for the same remittance advice. The paper remittance displays 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displays 27 bytes (9999999999 – [year] #############).
• Enhancement - The updated numbering sequence for the paper remittance and corresponding 835 (ERA) will contain the same ten-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

 

2. Searching for non-payment remittance:

• Current - When using Remit Inquiry, the search field requires a date range and tax ID to locate a specific remittance due to same number scenario being used for every non-payment remittance.
• Enhancement - Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers will provide a faster and simplified process to find the specific remittance.

 

The way your organization receives remittances and payments is not changing; we have simply enhanced the numbering for the non-pay remittances. These changes will not impact previously issued non-payment remittance advices. We’ll provide further information before this change is implemented. 

 

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The American Cancer Society estimates there will be approximately 1,898,160 cancer cases diagnosed in 2021. That’s the equivalent of 5,200 new cases each and every day. ¹ The good news is, patients say they are more likely to get screened when you recommend it. What else can you do to influence cancer screenings?²

1. Understand the power of the physician recommendation.
   • Your recommendation is the most influential factor in whether a person decides to get screened.
   • Patients are 90% more likely to get a screening when they reported a physician recommendation.
   • “My doctor did not recommend it,” is the primary reason for screening avoidance.
2. Recognize cultural barriers that may impact your diverse patients
   • Culturally sensitive conversations with your patients can help with fear, embarrassment, anxiety, and misconceptions about screenings.
   • Go to com for information and resources.
3. Measure the screening rates in your practice; it may not be as high as you think.
   • Set goals to get screening rates up.
   • Follow the HEDIS guidelines included in this article to help accurately track your care gap closures.
4. More screening doesn’t have to mean more work for you.
   • Reach out to us about available member data – we may be able to help identify or supply access to data for those members who are due screenings.
   • Develop a reminder system, which has been demonstrated to be effective, to remind you and staff that patients have screenings due.
5. Help members access benefit information about screenings to eliminate the cost barrier.
   • Log onto com and use the Patient Information tab to run an Eligibility and Benefits inquiry.
   • Members can access their benefit information by logging onto com, through Live Chat, or by downloading the Sydney Health App.
   • Blue Cross Blue Shield Service Benefit Plan members, also known as Federal Employee Program® members, can access their benefit information by logging onto org, or by downloading the fepblue App from the Apple Store or on Google Play.

 

Measure up: HEDIS® measure specifications for cancer screenings for women

 

Cervical cancer screening

 

Organized and continuous screenings along with removal of precancerous lesions can lead to a 60% decrease in cervical cancer.³

 

Cervical cancer screening is measured by the percentage of women, 21 to 64 years of age who were screened for cervical cancer using either of the following criteria:

• Women 21 to 64 years of age who had cervical cytology performed within the last 3 years.
• Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
• Women 30 to 64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years.

 

Description	CPT/HCPCS Code
Cervical cytology lab test	CPT: 88141–88143, 88147, 88148, 88150, 88152–88153, 88164–88167, 88174, 88175 HCPCS: G0123, G0124, G0141, G0143, G0145, G0147, G0148, P3000, P3001, Q0091 LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
hrHPV lab test	CPT: 87620–87622, 87624, 87625 HCPCS: G0476 LOINC: 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0
Absence of cervix diagnosis	ICD-10-CM: Q51.5, Z90.710, Z90.712
Hysterectomy with no residual cervix	CPT: 51925, 56308, 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290–58294, 58548, 58550, 58552, 58553, 58554, 58570–58573, 58575, 58951, 58953, 58954, 58956, 59135 ICD-10-PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ

 

Breast cancer screening

More women in the United States are surviving and thriving after breast cancer than ever before. In fact, in the last 30 years, the breast cancer death rate has dropped an astounding 40%. The decreases are believed to be the result of finding breast cancer earlier through screening, increased awareness, and better treatments.⁴

 

Breast cancer screening is measured by the percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer. Compliant members have one or more mammograms any time on or between October 1^st two years prior to the measurement year and December 31^st of the measurement year.

 

Description	CPT/HCPCS Code
Mammography	CPT: 77057, 77061–76063, 77065–77067 LOINC: 24604-1, 24605-8, 24606-6, 24610-8, 26175-0, 26176-8, 26177-6, 26287-3, 26289-9, 26291-5, 26346-7, 26347-5, 26348-3, 26349-1, 26350-9, 26351-7, 36319-2, 36625-2, 36626-0, 36627-8, 36642-7, 36962-9, 37005-6, 37006-4, 37016-3, 37017-1, 37028-8, 37029-6, 37030-4, 37037-9, 37038-7, 37052-8, 37053-6, 37539-4, 37542-8, 37543-6, 37551-9, 37552-7, 37553-5, 37554-3, 37768-9, 37769-7, 37770-5, 37771-3, 37772-1, 37773-9, 37774-7, 37775-4, 38070-9, 38071-7, 38072-5, 38090-7, 38091-5, 38807-4, 38820-7, 38854-6, 38855-3, 42415-0, 42416-8, 46335-6, 46336-4, 46337-2, 46338-0, 46339-8, 46350-5, 46351-3, 46356-2, 46380-2, 48475-8, 48492-3, 69150-1, 69251-7, 69259-0
Online assessments	CPT: 98970–98972, 99421–99423, 99457 HCPCS: G0071, G2010, G2012, G2061–G2063
Telephone visits	CPT: 98966–98968, 99441–99443

 

Chlamydia screening in women

Sexual health is an essential element of overall health and well-being. Many patients want to discuss their sexual health with you, but most of them want you to bring it up. The National Coalition for Sexual Health has published a guide to help physicians feel comfortable about the conversation. Get a copy of the Sexual Health and Your Patients: A Providers Guide by clicking on the title or through this website: ctcfp.org.

 

Chlamydia screening in women is measured by the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.

 

Description	CPT/HCPCS Code
Chlamydia tests	CPT: 87110, 87270, 87320, 87490–87492, 87810

 

1 CA: A Cancer Journal for Clinicians. Cancer Statistics, 2021 https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21654

2 http://thecanceryoucanprevent.org/wp-content/uploads/14893-80_2018-PROVIDER-PHYS-4-PAGER-11-10.pdf

3 National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/9253676/

4 Research to Help Women Prevent Breast Cancer or Live their best life with it. American Cancer Society. https://www.cancer.org/latest-news/research-to-help-women-prevent-breast-cancer-or-live-their-best-life-with-it.html

 

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In late 2020, the Price Transparency final rule and the Consolidated Appropriations Act (CAA) were enacted. By law, many of these provisions require that Anthem Blue Cross and Blue Shield (Anthem) must disclose pricing and other information previously not available publicly. Below is a summary of provisions that may impact you. Some sections of these laws are pending further rulemaking/regulations.

 

Transparency in pricing regulation – Overview of changes and action Anthem is taking

 Transparency requirements will be phased in over three years beginning July 2022 as follows:

 

Plan years that begin	Regulation requirements	Anthem’s action
On or after January 1, 2022	Anthem must make three separate machine-readable files in a standardized format available to the public, including stakeholders such as consumers, researchers, employers, and third-party developers. The three files must be placed on a publicly available website and updated monthly.   Negotiated in-network provider rates for all covered items and services. Historical payments to, and billed charges from, out-of-network providers. In-network negotiated rates and historical net prices for all covered prescription drugs administered by Anthem at the pharmacy location level.   The rate information is required to include the provider’s National Provider Identifier (NPI) and taxpayer identification number (TIN).	We are developing the files that will be available through our website for the data we administer and maintain. Machine Readable Files will be published beginning July 1, 2022, except those for prescription drugs, which are pending further rulemaking.
January 1, 2023	Anthem must make personalized out-of-pocket cost information and the underlying negotiated rates for 500 covered healthcare items and services – including prescription drugs – available to participants, beneficiaries, and enrollees.	As required, we are on track with making information available through an internet-based, self-service tool and in paper form upon request.
January 1, 2024	Anthem must expand our transparency tools to encompass all covered items and services.	We continue to review and assess guidance regarding the regulation and are working to comply with requirements.

 

 

Consolidated Appropriations Act (CAA)

As a part of the Consolidated Appropriations Act or CAA, there are significant new health plan requirements, including protections for patients from surprise medical bills and other significant health coverage related provisions.  Most of these provisions are effective January 1, 2022.

 

Regulatory detail needed for full implementation is still pending in most cases. However, the Centers for Medicare & Medicaid Services (CMS) has indicated good faith compliance should be pursued pending regulatory implementation detail.

 

Some key provisions of the CAA, effective January 1, 2022, are listed below that may impact your business interactions with us.

 

Surprise billing and independent dispute resolution process

The CAA requires that patients be held responsible for only in-network cost sharing amounts, including deductibles, in emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider (including air ambulance providers). The provision also prohibits out-of-network providers from balance billing except in limited circumstances where the out-of-network provider has obtained a notice and consent from the patient. An independent dispute resolution (IDR) process is available when an out-of-network provider and Anthem cannot reach an agreement on payment. 

 

In July 2021, an interim final rule (IFR) provided some of the regulatory detail around cost sharing calculations for surprise billing.   Further regulatory guidance is expected in the coming months – including guidance regarding the IDR process.

 

Anthem is moving forward with changes in calculations and payment based on the guidance received to date.  We will continue to monitor for additional regulatory guidance.

 

Increasing transparency by removing contract provisions known as gag clauses that may prohibit health plans from disclosing price and quality information  

The CAA requires Anthem to provide access to provider-specific price or quality of care information, through a consumer engagement tool or any other means, to referring providers, enrollees, or individuals eligible to become Anthem enrollees.

 

Due to the gag clause provision, we will no longer be able to allow suppression of price and quality data upon provider request.

 

Member identification card changes

Member ID cards issued for plan years on and after January 1, 2022, must include information to ensure that members know how to access current information regarding their deductibles and out-of-pocket limits.  Additionally, member ID cards must include a telephone number and internet address for members to use for assistance should they have questions such as whether a provider participates in our networks. We encourage in-network providers to continue to use Availity for member cost share information.

 

Continuity of care  

As a part of the Consolidated Appropriations Act, there is a continuity of care protection requirement that allows patients with serious or complex care needs (continuing care patients) to have up to a 90-day period of continued coverage at the same terms and conditions when a provider changes network status or an insured group contract terminates.  This provides continued coverage at in-network cost sharing rates to allow for a transition of care to an in-network provider or until the patient is no longer a continuing care patient under the CAA. 

 

Anthem must notify individuals who qualify as continuing care patients at the time of the provider’s termination as an in-network provider of the option to continue care for the transitional period of up to 90 days.  Providers subject to this provision must accept the continued in-network payment as payment in full and otherwise comply with all policies, procedures and quality standards Anthem imposes.  If an insured group terminates with Anthem, continuing care patients also have up to a 90-day period of continued care at in-network cost sharing rates. Applicable contract rates will apply for providers.

 

Protecting patients and improving the accuracy of provider directory information

Anthem must maintain a provider directory available to consumers online that includes a list of the in-network providers and facilities. Anthem must verify provider/facility name, address, specialty, phone number and digital contact information at least every 90 days.

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African American and Hispanic women have higher risk of death from breast cancer than their White counterparts.¹

 

Race and ethnicity continue to be a factor influencing mammography use according to a National Library of Medicine.² While research and studies show that annual screenings greatly reduce breast cancer deaths, 35% of women still do not get an annual mammogram and the percentage is even higher in African American and Hispanic women.

 

While African American and White women get breast cancer at about the same rate, African American women have a higher rate of death from breast cancer, according to the Centers for Disease Control and Prevention. African American and Hispanic women are 20% more likely to be diagnosed with advanced stage breast cancer, and they have, respectively, up to 70% and 14% increased risk of death.⁴

 

A common theme stressed in all of the major breast screening guidelines has been for providers to talk with patients about mammography. But when? Knowing that younger African American and Hispanic women are already considered a “high-risk” group, the conversation can be confusing to your patient under 30.

 

Help your African American and Hispanic patients understand the importance of early screening by sharing information with them about their unique risks. We’ve included links to videos that address breast cancer screening in both African American and Hispanic women. We hope you will share it with your patients either in your waiting rooms, or by offering to play them during their visits.

 

Why mammograms matter for Black women.

Why mammograms matter for Hispanic women.

 

There are other resources available through the Center for Disease control and the American Cancer Society, to name a few. The American College of Radiology has a Talking to Patients about Breast Cancer Screening CME Toolkit that offers CME credits for completing the toolkit.

 

Talking to women about taking everyday steps to lower their risk for getting breast cancer is the first step in closing disparity gaps in care.

 

1 https://jamanetwork.com/journals/jamaoncology/article-abstract/2775169

2 https://pubmed.ncbi.nlm.nih.gov/8909641/

3 https://www.acr.org/Media-Center/ACR-News-Releases/2019/ACR-Offers-New-Talking-to-Patients-about-Breast-Cancer-Screening-CME-Toolkit

4 https://www.eurekalert.org/news-releases/475470

 

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The clinical appeal process is designed to provide an appropriate and timely review when providers disagree with a decision made by Anthem Blue Cross and Blue Shield (Anthem) The procedures also meet requirements of state laws and accreditation agencies. Appeals can be made verbally, in writing, or by using Interactive Care Reviewer through the Availity portal.

Clinical appeals refer to a situation in which an authorization or claim for a service was denied as not medically necessary or experimental/investigational. Medical necessity and prior authorization appeals are different than claim payment disputes and should be submitted in accordance with the clinical appeal process.  

To learn more about our appeals process in detail, we encourage you to go to the Anthem provider manual, available on our website at anthem.com/provider.

 

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Medicare Advantage

 

Anthem Blue Cross and Blue Shield (Anthem) is offering Special Needs Plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. Some SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid, which include supplemental benefits such as hearing, dental, vision, and transportation to medical appointments. Some SNP plans include a card or catalog for purchasing over-the-counter items, but SNPs do not charge premiums.

 

SNP members benefit from a model of care (MOC) that is used by Anthem to assess needs and coordinate care. Each member receives a comprehensive health risk assessment (HRA) within 90 days of enrollment and annually thereafter, which covers physical, behavioral, and functional needs, along with a comprehensive medication review. The HRA is then used to create a member care plan. Members with multiple or complex conditions are assigned a health plan case manager.

 

SNP HRAs, care plans, and case managers support members and their providers by helping identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments plus providing navigation and coordination of services across the Medicare and Medicaid programs.

Provider training required

Providers contracted for SNP plans are required to complete an annual training to keep up-to-date with plan benefits and requirements, including details on coordination of care and MOC elements. Every provider contracted for SNP is required to complete an attestation stating they have completed their annual training. These attestations are located at the end of the self-paced training document.

 

To take the self-paced training, please go to the MOC Provider Training link at availity.com.

 

How to access the Custom Learning Center on the Availity Portal:*

1. Log in to the Availity Portal at availity.com.
   1. At the top of the Availity Portal, select Payer Spaces and select the appropriate payer.
2. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
3. In the Custom Learning Center, select Required Training.
4. Select Special Needs Plan and Model of Care Overview.
5. Select Enroll.
6. Select Start.
7. Once the course is completed, select Attestation and complete.

 

Not registered for the Availity Portal?

Have your organization’s designated administrator register your organization for the Availity Portal.

1. Visit availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

 

FAQs

 

What does it mean to be dual-eligible? What is a D-SNP?

The term dual-eligible refers to people with Medicare coverage who also qualify for some type of state Medicaid benefit — meaning that these members are eligible for both Medicaid and Medicare. These individuals may have higher incidence of chronic conditions, cognitive impairments, and functional limitations. D-SNPs are special Medicare Advantage plans that enroll only dual-eligible people, providing them with more intensive coordination of care and services than those offered by traditional Medicare and Medicare Advantage plans.

 

What is a SNP Model of Care?

The Centers for Medicare & Medicaid Services (CMS) requires Special Needs Plans (SNPs) to have a model of care (MOC) that describes how the SNP will administer key components of care management programs, including assessments and training. The MOC describes the unique needs of the population being served and how Anthem Blue Cross and Blue Shield (Anthem) will meet those needs. Each SNP MOC is evaluated and scored by the NCQA and approved by CMS.

 

How does the MOC help physicians?

The three major components of the MOC — 1) the health risk assessment (HRA), 2) Care Plan, and 3) case manager — support providers in serving D-SNP members. Each member receives a comprehensive HRA that covers physical, behavioral, and functional needs, along with a comprehensive medication review. Anthem staff use the HRA information to create a Care Plan. Members with multiple or complex conditions may be assigned to a case manager.

 

These key MOC components identify and escalate potential problems for early intervention, ensure appropriate and timely follow-up, and help coordinate services across Medicare and Medicaid programs. Through the provider website, providers have access to review the Care Plan, the results of the HRA, and other information to help manage care.

 

How are transitions of care managed?

Anthem case managers are involved in transitions of care (for example, discharge from hospital to home for those at high-risk of readmission). Such transitions may trigger a reassessment and updates to the member’s Care Plan as needed. Following a discharge, case managers help ensure that D-SNP members see their PCP within a week and work through barriers that members experience in adhering to post discharge medication regimens.

 

Who makes up the Interdisciplinary Care Team (ICT)?

Members of the ICT include any of the following: nurses, physicians, social workers, pharmacists, the member and/or the member’s caregiver, behavioral health specialists, or other participants as determined by the member, the member’s caregiver, or a relative of the member.

 

Providers who care for Anthem members are considered participants in the ICT and may be contacted by a case manager to discuss the member’s needs. The case manager may present recommendations concerning care coordination or other needs. The goal of the ICT is to assist providers in managing and coordinating patient care.

 

Do I have to become a Medicaid provider?

You are not required to become a Medicaid provider, but we recommend that you do. Even if you are only providing services covered by Medicare Part A or Part B to SNP members, we recommend that you attain a Medicaid ID because the state Medicaid agency may require this for the Medicare cost share.

 

How do I file claims for SNP members?

Claims for services to SNP members are filed the same way claims are filed for Anthem members enrolled in Medicare Advantage who are not part of SNP. Providers should ensure that the claim has the correct member ID (including the prefix).

 

How is the SNP member’s cost-sharing handled?

SNP benefits are administered similarly to Medicare fee-for-service benefits. Upon receiving the Explanation of Payment (EOP) from Anthem, you should bill the state Medicaid agency or the applicable Medicaid managed care organization (MCO) contracted with the state for processing of any Medicare cost-sharing applied.

 

Medicare cost-sharing is paid according to each state’s Medicaid reimbursement logic. Some states do not reimburse for Medicare cost sharing if the payment has already met or exceeded Medicaid reimbursement methodology.

 

Do I have to file claims twice for SNP members?

Yes, when you treat Anthem members enrolled in a SNP, you will file the initial claim with Anthem and then bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for Medicare cost sharing processing. Please use the same electronic claim submission or address you currently use for Anthem claims filing.

 

Do SNP members have access to the same prescription drug formulary as other Anthem members enrolled in Medicare Advantage?

Yes, SNP members have coverage for the same prescription drugs listed on the Anthem prescription drug formulary for Medicare Advantage.

 

Please note that in California, the tier placement may vary. Be sure to review the plan’s specific formulary for details on California SNPs, as the formulary depends on the market.

 

What are SNP benefits for Anthem members?

The SNP for Anthem members covers all Medicare Part A and Part B services and includes full Part D prescription coverage. Anthem also covers a range of preventive services with no-cost sharing for the member. In addition, the SNP includes coverage for supplemental benefits that may include routine dental, vision, and nonemergency medical transportation. A summary of the SNP benefits is posted on the provider website for Anthem members.

 

Any Medicaid benefits available to the member will be processed under their Medicaid coverage directly with the state or the Medicaid organization in which the member is enrolled.

 

Does the SNP use the same procedure codes and electronic data interchange (EDI) payer codes?

Yes, the SNP uses the same procedure and payer codes and electronic filing procedures as other Medicare Advantage plans through Anthem.

 

Is the EDI payer ID for this product the same as others?

Yes, all the claim submission information will be the same (this applies to EDI and paper). Providers must submit this information with the correct ID. Please check the EDI section of the provider website for the correct payer codes to use for your market.

 

ABSCRNU-0255-21

 

Medicaid

 

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

• 2021 affirmative statement concerning utilization management decisions
• Medical drug benefit Clinical Criteria updates
• Medicaid continuous glucose monitoring systems
• Medication-assisted treatment (MAT) — ECHO series — launching October 6 at noon
• Race and ethnicity data to be published in provider directories

Medicaid

 

Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of a national drug code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

 

Clinical Criteria	HCPCS or CPT® code(s)	Drug	Generic name	Drug class
ING-CC-0179	J9037	Blenrep	Belantamab	Oncology
ING-CC-0180	J9349	Monjuvi	Tafasitamab-cxix	Oncology
ING-CC-0181	J3490	Veklury	Remdesivir	COVID-19

 

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 844-396-2330.

ANV-NU-0272-21

Medicaid

 

Effective for dates of service on and after November 1, 2021, the following specialty drug codes from current or new clinical criteria documents will require prior authorization.

 

Please note, inclusion of national drug code (NDC) on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Visit the Clinical Criteria website to search for the specific clinical criteria listed below. 

 

Clinical Criteria	HCPCS or CPT® code(s)	Drug	Drug classification
ING-CC-0170	J1823	Uplizna	Immunosuppressive agents
ING-CC-0172	J3490, J3590, C9071	Viltepso	Muscular dystrophies
ING-CC-0173	J3490, J3590	Enspryng	MISC conditions
ING-CC-0174	J3490, J3590, C9399	Kesimpta	Multiple sclerosis
ING-CC-0168	J9999, C9073	Tecartus	CAR-T
ING-CC-0171	J9223	Zepzelca	Cancer
ING-CC-0169	J9316	Phesgo	Cancer
ING-CC-0175	J9015	Proleukin	Cancer
ING-CC-0176	J9032	Beleodaq	Cancer
ING-CC-0178	J9262	Synribo	Cancer
ING-CC-0177	J3304	Zilretta	Osteoarthritis
ING-CC-0002	Q5122	Nyvepria	Blood cell deficiency
ING-CC-0038	J3110	Forteo	Osteoporosis

 

 

ANV-NU-0270-21

Medicaid

(Effective 01/01/22)

 

Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) allows reimbursement of sexually transmitted infection (STI) tests unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. We consider certain STI testing CPT^® codes to be part of a laboratory panel grouping. When Anthem receives a claim with two or more single tests laboratory procedure codes reported, we will bundle those two or more single tests into the comprehensive laboratory procedure code listed below.

 

Applicable single STI CPT codes:

• 87491: Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, amplified probe technique
• 87591: Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, amplified probe technique
• 87661: Infectious agent detection by nucleic acid (DNA or RNA); trichomonas vaginalis, amplified probe technique

 

Applicable comprehensive code:

• 87801: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique

 

Anthem will reimburse the more comprehensive, multiple organism code for infectious agent detection by nucleic acid, amplified probe technique (CPT code 87801), when two or more single test CPT codes are billed separately by the same provider on the same date of service. Reimbursement will be made based on a single unit of CPT code 87801 regardless of the units billed for a single code. No modifiers will override the edit.

 

For additional information, please review the Sexually Transmitted Infections Testing — Professional reimbursement policy at providers.anthem.com/nv.

 

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Medicaid

 

Comprehensive Diabetes Care HEDIS^® measure

The Comprehensive Diabetes Care HEDIS measure evaluates the percent of adult members 18 to 75 years of age with diabetes (type 1 and type 2) who had each of the following during the measurement year:

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (<8.0%)
• Retinal eye exam performed
• Blood pressure control (<140/90 mm Hg)

 

Kidney Health Evaluation for Patients with Diabetes

Additionally, the Kidney Health Evaluation for Patients with Diabetes measure was added as a first year HEDIS measure in 2020. This measure evaluates the percent of members 18 to 85 years of age with diabetes who received a kidney health evaluation, including an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR).

 

Record your efforts

Document results in the in the member’s medical record: HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test, GFR test.

 

Helpful tips:

• Have reminders set in your electronic medical record (EMR) to alert staff when a patient’s screenings are due.
• Provide reminders to patients for upcoming appointments and screenings.
• Draw labs in your office if available or refer patients to a local lab for screenings.
• Refer patients to participating eye professionals for annual retinal eye exams.
• Follow up on lab test, eye exams and specialist referrals and document in your chart.
• Telephone visits, e-visits and virtual check-ins are acceptable settings for blood pressure readings and should be recorded in the chart.
• Include Category II reporting codes on claims to reduce the burden of HEDIS medical record review.
• Educate patients on topics (for example, home monitoring of blood sugar and blood pressure, taking medications as prescribed, and other healthy lifestyle education like diet, exercise, and smoking cessation).

 

Other available resources:

• Clinical Practice Guidelines are available on our provider self-service website.
• Contact the Health Plan for a copy of Quality Measures Desktop Reference for Medicaid Providers and the HEDIS Benchmarks and Coding Guidelines for Quality.
• Diabetes programs may be available to our members, contact your Provider Solutions representative for more information.

 

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

 

ANV-NU-0246-21

Medicaid

 

**This article originally published in the July edition of Network Update. The original article was missing the last two paragraphs.**

As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address patients’ needs. Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) wants to help.

Cultural competency resources

Here is an overview of the cultural competency resources available on our provider website.

• Cultural Competency and Patient Engagement includes:
• The impact of culture and cultural competency on healthcare.
• A cultural competency continuum, which can help providers assess their level of cultural competency.
• Disability competency and information on the Americans with Disabilities Act (ADA).
• Caring for Diverse Populations Toolkit includes:
• Comprehensive information, tools and resources to support enhanced care for diverse patients and mitigate barriers.
• Materials that can be printed and made available for patients in provider offices.
  • Regulations and standards for cultural and linguistic services.
• My Diverse Patients offers:
• A comprehensive repository of resources to providers to help support the needs of diverse patients and address disparities.
• Courses with free continuing education credit through the American Academy of Family Physicians.
  • Free accessibility from any device (for example, desktop computer, laptop, phone or tablet), no account or login required.

 

To access these resources, go to providers.anthem.com/nv > Manuals, Directories, Training & More > Tutorials, Reference Guides and Other Resources.

 

In addition, providers can access Stronger Together, which offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

Prevalent non-English languages (based on population data)

Like you, Anthem wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the prevalent non-English languages spoken by 5% or 1,000 individuals in Nevada.¹

Prevalent non-English languages in NV

Spanish

 

Language support services

As a reminder, Anthem provides language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Please see the provider manual for details on what is available and how to access resources. In addition, the cultural competency resources shared above provide guidance on communicating and serving diverse populations effectively.

1 Source: American Community Survey, 2019 American Community Survey 1-Year Estimates, Table B16001, generated 10/04/2020.

 

ANV-NU-0224-21

Medicare Advantage

 

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

• 2021 affirmative statement concerning utilization management decisions
• May 2021 Medical Policies and Utilization Management Guidelines update
• Race and ethnicity data to be published in provider directories

Medicare Advantage

 

Effective November 1, 2021, the Clinical Criteria ING-CC-0005 will include a trial and inadequate response or intolerance to two preferred hyaluronan agents in the Part B medical step therapy precertification review. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as-is current procedure). Step therapy will not apply for members who are actively receiving non-preferred medications listed below.

 

Clinical Criteria are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

 

Clinical Criteria	Preferred drug(s)	Nonpreferred drug(s)
ING-CC-0005	Euflexxa (J7323) Supartz FX (J7321) Durolane (J7318) Gelsyn-3 (J7328)	Including but not limited to: Gel-One (J7326) GenVisc 850 (J7320) Hymovis (J7322) Monovisc (J7327) Orthovisc (J7324) Synvisc/Synvisc One (J7325) TriVisc (J7329) Hyalgan/Visco-3 (J7321) Triluron (J7332)

 

 

ABSCRNU-0266-21

Medicare Advantage

 

Instead of faxing multiple pages of medical records for HEDIS® studies, use Anthem Blue Cross and Blue Shield (Anthem)’s Remote EMR Access Service we offer to providers that allows us to access your EMR system directly to pull the documentation we need. Our Remote EMR Access Service helps reduce the time and costs associated with medical record retrieval while improving efficiency and lessening the impact on your office staff.

 

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 evidence related to the HEDIS® measures.
• We only view face sheets when there are demographic discrepancies.
• We exclude data related to hospice, long-term care, inpatient, and palliative care.

 

Let us help you! Getting started with Remote EMR Access is just one click away.

Download and complete this registration form and email it to us at Centralized_EMR_Team@anthem.com.

 

To learn more about our Remote EMR Access Service, view the Frequently Asked Questions below.

How do you retrieve our medical records?
We access your EMR 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 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 non-standard format, such as an in-office lab slip scanned into miscellaneous documents

 

What information do I need to submit to use your Remote EMR Access Service?
Complete the registration form that requests the following information:

• Practice/facility demographic information (e.g., address, National Provider ID, taxpayer identification numbers, etc.)
• EMR system information (e.g., type of EMR system, required access forms, access type – web based or VPN-to-VPN connection, special requirements needed for access, etc.)
• List of current providers/locations or a website for accessing this list. Also, if applicable, a list of providers affiliated with the group that are not in the EMR System.

 

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

 

ABSCRNU-0259-21

Medicare Advantage

 

(Effective 01/01/22)

Anthem Blue Cross and Blue Shield (Anthem) allows reimbursement of sexually transmitted infection (STI) tests unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. We consider certain STI testing CPT^® codes to be part of a laboratory panel grouping. When Anthem receives a claim with two or more single tests laboratory procedure codes reported, we will bundle those two or more single tests into the comprehensive laboratory procedure code listed below.

 

Applicable single STI CPT codes:

• 87491: Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, amplified probe technique
• 87591: Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, amplified probe technique
• 87661: Infectious agent detection by nucleic acid (DNA or RNA); trichomonas vaginalis, amplified probe technique

 

Applicable comprehensive code:

• 87801: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique

 

Anthem will reimburse the more comprehensive, multiple organism code for infectious agent detection by nucleic acid, amplified probe technique (CPT code 87801), when two or more single test CPT codes are billed separately by the same provider on the same date of service. Reimbursement will be made based on a single unit of CPT code 87801 regardless of the units billed for a single code. No modifiers will override the edit.

 

For additional information, please review the Sexually Transmitted Infections Testing — Professional reimbursement policy at anthem.com/medicareprovider.

 

ABSCRNU-0254-21