 Provider News NevadaSeptember 1, 2022 September 2022 Anthem Provider News - NevadaThis article was published in the August 2022 issue of Provider News; however, we inadvertently omitted the effective date. We have added the effective date of September 1, 2022, to the original article and included it below.
According to the American Medical Association (AMA) Current Procedural Terminology® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after September 1, 2022, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M.
If you have questions on this program, contact your contract manager or Provider Experience representative.
Register today for the Exploring the Intersection of Race and Disability forum hosted by Anthem
Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on September 21, 2022.
Anthem is committed to making healthcare simpler and reducing health disparities. We believe that continuing the discussion we started at our June 2022 event to deepen the conversation about the disability experience for people of is critically important. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.
Wednesday, September 21, 2022
1:00 p.m. to 2:30 p.m. PT
Please register for this event by visiting this link.
The Health Resources & Services Administration (HRSA) Women’s Preventive Services Guidelines recommend women receive at least one preventive care visit per year.
While many members may receive a standalone preventive care visit, well-women visits may also include prepregnancy, prenatal, postpartum, and interpregnancy visits. For members receiving prepregnancy, prenatal, postpartum, and/or interpregnancy care that is billed using a global maternity code (for example, CPT® 59400, 59510, 59610, 59618) or antepartum/postpartum codes (for example, CPT 59425, 59426, 59430), it is appropriate to submit a claim for a wellness visit (for example, CPT 99385, 99386, 99387, 99395, 99396, 99397) when recommended preventive care has been rendered for a member who has not received a wellness visit in the last year. This will help ensure recognition that recommended preventive services have been provided for our members.
Please note, wellness evaluation and management (E/M) codes should not be billed on the same day as global maternity or antepartum/postpartum codes. Providers should continue to verify eligibility and benefits for all members prior to rendering services.
Keeping your provider directory information current is key for members and your healthcare partners to engage with you seamlessly. Please review your information regularly and let us know if any of your information we show in our online directory has changed.
To update your information, use our online Provider Maintenance Form. Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Operational procedures
Operational procedures for guided access HMO are the same as any other local HMO plan. Please use the contact information below.
Claims should be filed directly to your local Anthem Blue Cross and Blue Shield (Anthem) office, either electronically or mailed to:
Anthem Blue Cross and Blue Shield
P.O. Box 5747 Denver, CO 80217-5747
Online self-service options are available to providers, giving you access to the same information you receive when calling customer service, and provides patient specific information, such as eligibility, benefits, claim status, line-level detail, and payment information. These options include:
- Availity:* A multi-payer secure provider website available at https://availity.com
- Electronic data interchange (EDI) available at https://anthem.com/edi
- Interactive voice response (IVR)/Provider Customer Service available at 877-833-5742
Referrals for guided access HMO:
- Submit a referral via one of the following options:
- Secure portal: Submit referral request on Availity
- Public website: Submit the Anthem Referral Form via email
(CONVUM-Wellpoint@wellpoint.com) or fax (800-763-3142)
- Phone: 800-336-7767
- Referrals required for most specialty care
- The following specialties or services do not require a referral from PCP to an in-network specialist:
- Addiction medicine
- Applied behavior analyst
- Emergent or urgent care
- Gynecology
- Licensed professional counselor
- License clinical social worker
- Midwife
- Neonatal/perinatal
- Obstetrics/gynecology
- Ophthalmology
- Optometry
- Psychiatry
- Psychology
- Retail health clinic
- As long as the provider is in the HMO or Pathway X HMO network, the referral will be approved.
- Referrals must be completed by the member’s PCP.
- Referrals to a specialist are required for guided access HMO members.
- Specialist to specialist referrals do require a referral from the member’s PCP.
Submit a referral via Availity:
        
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.
This communication applies to the Commercial and Medicare Advantage programs from
Anthem Blue Cross and Blue Shield (Anthem).
We are carefully monitoring the recent outbreak of monkeypox infections in the U.S. and are working to support our members and our network care providers with information to help you respond appropriately in the context of your patient population.
The best source of up-to-date information is at the Centers for Disease Control and Prevention which has a dedicated monkeypox page for healthcare professionals.
In addition to resources for care providers, the CDC has developed educational materials for the public, available for free download online.
FAQs
Who can become infected?
With this recent outbreak, monkeypox has spread through close, intimate contact with someone who has monkeypox. Many cases initially occurred in men who have sex with men. However, anyone can get monkeypox.
How dangerous is the disease?
Monkeypox virus belongs to poxvirus family and infection is rarely fatal. Patients whose immune system is compromised are most at risk for severe disease, along with children younger than 8 years old, pregnant and breastfeeding people, and people with a history of atopic dermatitis or other active skin conditions.
What are monkeypox symptoms?
Patients often have a characteristic rash (well-circumscribed, firm, or hard macules evolving to vesicles or pustules) on a single site on the body. Patients may also present with a fever and muscle aches. The rash may start in the genital and perianal areas. The lesions are painful when they initially emerge, but can become itchy as they heal, and then go away after two to four weeks. Symptoms can be similar or occur at the same time as sexually transmitted infections.
How does monkeypox spread?
Monkeypox does not spread easily between people without close contact. Person-to-person transmission is possible by skin-to-skin contact with body fluids or monkeypox sores, or respiratory droplets during prolonged face-to-face contact, and less likely through contaminated items such as bedding, clothing, or towels. Patients are contagious until the scabs heal and are replaced by new skin.
Is there a monkeypox vaccine?
Yes, although at the time of this writing, availability is limited. Smallpox and monkeypox vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox, and vaccination after a monkeypox exposure may help prevent the disease or make it less severe. You can access the CDC’s vaccination updates online.
How can monkeypox be treated?
There are no treatments specifically for monkeypox virus infections. However, antiviral drugs and vaccines developed to protect against smallpox may be used to prevent and treat monkeypox virus infections.
Do I need to report a case of suspected monkeypox?
Yes. Contact your state health department if you have a patient with monkeypox. They can help with testing and exposure precautions.
What are the behavioral health impacts of monkeypox?
Studies reporting psychiatric symptoms have indicated that the presence of anxiety, depression, or low mood is common among hospitalized patients with monkeypox infection. Care providers can help by listening with compassion, understanding underlying behavioral health concerns that may be heightened during isolation, and refer patients to the appropriate level of support following a monkeypox diagnosis.
The Prefix Reference List and Networks at a Glance documents have been updated and are now available on the anthem.com/provider website.
The Prefix Reference List assists providers in identifying member plans, plan types, Provider Service numbers, and mailing addresses. You can access the revised Prefix Reference List here.
The Networks at a Glance document assists providers in finding more information about networks, plans, and alpha prefixes. The revised Networks at a Glance is available here.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
Effective July 1, 2022, Anthem recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Anthem contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims.
The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Anthem for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.
The following Anthem benefit plans are in scope for participation in HiH:
- Anthem Commercial
- Medicare Advantage (Individual and Group)
- Medicare Advantage Special Needs plans, including Dual-Eligible Special Needs (D-SNP)
The following Anthem plans are out of scope for participation in HiH:
Note:
- Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Anthem suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
- Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
- Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
- Facility shall not bill Anthem or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
- Notify Anthem immediately through the utilization management nurse assigned to the HiH case when:
- An applicable member is admitted to the HiH program
- A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
- As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Anthem Agreement and/or as outlined in the applicable Anthem provider manual.
We will continue to update billing guidance as these programs evolve.
We appreciate the positive feedback you have shared about the new Claim Status Send Attachment feature. This enhancement to the attachment process enables you to submit an attachment directly to your claim at availity.com* by simply selecting the new Send Attachment button. We want to keep that positive momentum by answering your questions about those times when you are not able to find your claim in the Claim Status application using Availity Essentials. Here are a few suggestions:
- Double check your search information. Is the member information entered correctly? Many times, it is as simple as double checking the basic information needed to search for the claim.
- Do you have a claim number? If we have requested additional information to process your claim, the claim number will be included in the letter to you. Use this claim number to search for your claim.
- If you have located your claim, but the Send Attachment feature is not displayed, we have a solution for you:
- From the Claims & Payment tab, select Attachments – New. This will take you to your Attachments Dashboard.
- From the Attachments Dashboard, select Send Attachment.
- From the dropdown, select Medical Attachment.
- Complete the form and use the Add Attachment button to upload your files.
- Select Send Attachments, and your documents will be attached to your claim.
Claims attachment learning opportunities
In collaboration with Availity Essentials, we have made it easy for you to learn when it is convenient for you. Through this on-demand webinar, learn how to submit claim attachments through Claim Status. Go here to access the course. If live webinars fit into your schedule, use go here to sign up today.
All members on a product with referral management will have an attributed PCP within the product parameters:
- Nevada utilizes PMG designation for member attribution.
- Nevada uses PMG assignment, or member selection happens at the PMG level when there is a group practice in place.
Application for all products within:
- Guided Access HMO
- Pathway X Guided Access HMO
- Convenient Care HMO (Launching January 2023)
Referral parameters:
- Referral orders must be created by the system attributed PCP of the member.
- Referrals must be limited to an in-network provider only; if PCP is seeking a referral for an
out-of-network (OON) provider, then all OON authorization processes must be followed.
- Specialist claims require a referral or will be denied, except as noted below.
- Exception: The following specialties do not require referrals when in-network (procedure codes listed in Exhibit 1):
- Optometry
- Mental:
- Behavioral Health
- Substance use disorder (SUD) providers
- Gynecology
- Routine maternity/obstetrics
- Dental
- Addiction medicine
- Emergent or urgent services
- Pediatric PCP Services
- Maximum of three visits to specialist per PCP referral. After the third visit, member must return to PCP to obtain a new referral. If a PCP believes additional referrals are required, then the PCP must contact Anthem Blue Cross and Blue Shield directly for a referral.
- All referrals expire in 90 days.
Open the attached PDF to view the "Referral Exclusion List and Procedure Codes (Exhibit 1 – as of July 20, 2022)."
Material adverse change
Anthem Blue Cross and Blue Shield (Anthem) and our subsidiary company, HMO Nevada, are pleased to provide you with our updated and new Medical Policies.
Anthem will also be implementing changes to our Clinical Utilization Management (UM) Guidelines that are adopted for Nevada. The Clinical UM Guidelines published on our website represent the Clinical UM Guidelines currently available to all plans for adoption throughout our organization. Because local practice patterns, claims systems, and benefit designs vary, a local plan may choose whether or not to implement a particular Clinical UM Guideline. The link below can be used to confirm whether or not the local plan has adopted the Clinical UM Guideline(s) in question. Adoption lists are created and maintained solely by each local plan.
The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.
On July 1, 2022, Anthem sent notification of the new medical policies listed effective for service dates on or after October 1, 2022. The notification also indicated effective July 1, 2022; prior authorization (PA) was required for these policies. Please note, the revisions to the July 1, 2022, notification as follows:
- October 1, 2022: Effective date for policies requiring PA
- October 1, 2022: Effective date for policies to be reviewed post-service.
- Post-service review is required at the point of claim submission for not otherwise classified codes.
New Medical Policies effective for service dates on and after October 1, 2022:
DME.00046 Intermittent Abdominal Pressure Ventilation Devices
This document addresses the use of intermittent abdominal pressure ventilation devices:
- Considered investigational and not medically necessary for all indications.
- PA required effective October 1, 2022.
DME.00047 Rehabilitative Devices with Remote Monitoring
This document addresses the use of rehabilitative devices with remote monitoring and adjustment capabilities intended to evaluate and improve muscle strength and range of motion while reporting session data to the individual’s provider:
- Considered investigational and not medically necessary for all indications.
- Post service review required effective October 1, 2022.
DME.00048 Virtual Reality-Assisted Therapy Systems
This document addresses the use of virtual reality-assisted therapy systems that may be used in the management of pain, cognitive or motor rehabilitation, treatment of procedural anxiety, and promotion of weight control:
- Considered investigational and not medically necessary for all indications.
- Post service review required effective October 1, 2022.
GENE.00059 Hybrid Personalized Molecular Residual Disease Testing for Cancer
This document addresses hybrid personalized molecular residual disease (MRD) testing for oncologic disease management. This personalized testing occurs in a two-step process. The first step involves whole exome sequencing (WES) of the tumor tissue. In the second step, information about the tumor learned from the WES is used to develop a personalized assay to detect circulating tumor DNA (ctDNA) that assesses MRD. Commercially available personalized MRD tests include the Signatera™ test (Natera Inc.,* San Carlos, CA) and the RaDaR™ test (Inivata,* Research Triangle Park, NC):
- Considered investigational and not medically necessary for all indications.
- PA required effective October 1, 2022.
LAB.00048 Pain Management Biomarker Analysis
This document addresses a new pain biomarker test, the Foundation Pain Index (FPI), which is a test panel of pain functional biomarkers in urine and is intended to identify sources of chronic pain. The FPI involves analysis of urine by liquid chromatography tandem mass spectrometry (LCM/MS) of a panel of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid [3-HPMA], quinolinic acid, kynurenic acid). It is suggested that nutritional deficiencies (such as in Vitamin B12 and B6), oxidative stress and metabolic abnormalities can lead to pain syndromes, and that these abnormalities can be identified through this testing for these pain biomarkers:
- Considered investigational and not medically necessary for all indications.
- PA required effective October 1, 2022.
MED.00139 Electrical Impedance Scanning for Cancer Detection
This document addresses the use of electrical impedance scanning for cancer detection:
- Considered investigational and not medically necessary for all indications.
- Post-service review required effective October 1, 2022.
TRANS.00039 Portable Normothermic Organ Perfusion Systems
This document addresses use of a portable normothermic organ machine perfusion and monitoring medical device used to preserve donor organs in a near-normothermic state from retrieval until transplantation. This document does not address static cold storage or other forms of solid organ preservation:
- Considered medically necessary when used for preservation of donor lung pairs initially deemed unacceptable for procurement and transplantation based on limitations of cold storage preservation, that is: age greater than 55, PaO2/FiO2 less than 300 mmHg, donation after cardiac death (DCD) donors, ischemic time greater than 6 hours).
- Considered medically necessary when used for the preservation of an organ initially deemed unacceptable and when criteria (1 or 2) below are met:
- Organ Care System Liver: Liver allografts from donors after circulatory death (DCD) less than or equal to 55 years old and with less than or equal to 30 minutes of warm ischemic time, macrosteatosis less than or equal to 15%
- OrganOx metra System: liver allografts from donors after DCD less than or equal to 40 years of age, with less than or equal to 20 minutes of functional warm ischemic time, and macrosteatosis less than or equal to 15%.
- Considered investigational and not medically necessary when the above criteria are not met, including but not limited to the preservation of other solid donor organs, including the heart (that is, OCS Heart System), or preservation of standard criteria donor organ.
- Post-service review effective October 1, 2022.
Procedure codes to require PA, effective December 1, 2022:
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications:
- Code 0398T — Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed.
- SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir):
- Code 0450T — Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (list separately in addition to code for primary procedure).
- SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures:
- Code 11922 — Tattooing, intradermal introduction of insoluble opaque pigments to correct defects of skin, including micropigmentation.
- ANC.00007 Cosmetic and Reconstructive Services: Skin Related:
- Code 11922 — Tattooing, intradermal introduction of insoluble opaque pigments to correct defects of skin, including micropigmentation.
- Code 15787 — Abrasion; Add'l 4 Lesions/<.
- CG-SURG-27 Gender Affirming Surgery:
- Code 11922 — Tattooing, intradermal introduction of insoluble opaque pigments to correct defects of skin, including micropigmentation.
- SURG.00121 Transcatheter Heart Valve Procedures:
- Code 33419 — Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (list separately in addition to code for primary procedure).
- SURG.00037 Treatment of Varicose Veins (Lower Extremities):
- Code 36474 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (list separately in addition to code for primary procedure).
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone:
- Code 37239 — Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (list separately in addition to code for primary procedure).
- Code 37249 — Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (list separately in addition to code for primary procedure).
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis:
- Code 43192 — Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance.
- Code 43201 — Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance.
- Code 43210 — Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed.
- SURG.00096 Surgical and Ablative Treatments for Chronic Headaches:
- Code 64787 — Implantation, nerve end into bone/muscle.
Anthem’s Medical Policies and Clinical UM Guidelines are developed by our national Medical Policy and Technology Assessment Committee. The Committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.
All coverage written or administered by Anthem excludes from coverage, services, or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set in Anthem’s Medical Policies. Review procedures have been refined to facilitate claim investigation.
Anthem’s Medical Policies and Clinical UM Guidelines are available online
The complete list of our Medical Policies and Clinical UM Guidelines can be accessed on Anthem’s website. Visit https://anthem.com and select Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as Your State. Select View Medical Policies & Clinical UM Guidelines. Either enter the keyword, code, or select the link for Full List page to search the policy for your inquiry.
To view the list of specific Clinical UM Guidelines adopted by Nevada, navigate to the View Medical Policies & UM Guidelines page. Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada.
In the December 2021 edition of Provider News, we announced that a new commercial reimbursement policy titled Modifier 66 Surgical Teams – Professional would be effective for dates of service on or after March 1, 2022. The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
Modifier 66: Surgical Teams — Professional: Under this reimbursement policy, Anthem Blue Cross and Blue Shield (Anthem) allows the use of procedures eligible for surgical teams when billed with modifier 66.
Anthem follows the Centers for Medicaid and Medicare Services (CMS) Medicare physician fee schedule (MPFS) team surgery payment indicators and will allow services requiring team surgery billed with CMS MPFS payment indicator 1 (sometimes) and 2 (always) and will deny services billed with the indicator 0 (never) and 9 (not applicable).
For specific policy details, visit our reimbursement policy page, at anthem.com/provider.
Material adverse change
(Effective 12/01/2022)
Beginning with date of services on or after December 1, 2022, Modifier FT is only allowed for reimbursement on critical care codes 99291, 99292, 99468, 99469, 99471, 99472, 99475, and 99476.
Modifier FT was created by the Centers for Medicare & Medicaid Services (CMS) and is included in our Claims Impacting Adjudication list located in the Related Coding section of our Modifier Rules policy (professional).
Modifier FT is defined as an unrelated evaluation and management (E/M) visit during a postoperative period or on the same day as a procedure or another E/M visit. (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated).
For specific policy details, visit the Anthem Blue Cross and Blue Shield Reimbursement policy page at anthem.com/provider.
In the December 2021 edition of Provider News, we announced that an update to our reimbursement policy titled Assistant at Surgery – Professional, effective for dates of service on or after March 1, 2022. The effective date of the policy has changed. The policy will now be effective for dates of service on or after November 1, 2022.
This policy follows the Centers for Medicare & Medicaid Services (CMS) guidelines for the codes designated as MPFS Assistant Surgery payment indicator 2 always requiring an assistant surgeon. Codes identified with MPFS Assistant Surgery payment indicators 0, 1, and 9 are not allowed for reimbursement.
For specific policy details, visit the Anthem Blue Cross and Blue Shield Reimbursement policy page at anthem.com/provider.
Summary of update
Effective October 1, 2022, Anthem Blue Cross and Blue Shield (Anthem) and AIM Specialty Health®* (AIM), a separate specialty benefits management company, will launch a new Back Pain Management Program for fully insured members, as further outlined below.
Who is AIM?
Anthem has an existing relationship with AIM in the administration of other programs. Anthem is excited to expand this relationship to include additional services. AIM works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.
What is the Back Pain Management Program?
In pursuit of the commitment to improve healthcare quality and costs, we have created a new voluntary Back Pain Management Program to help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.
The program will be utilizing predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.
Our member engagement process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors.
- Risk stratification to ensure the appropriate level of support is provided.
- Targeted outreach to members through our digital engagement platform, email, and calls.
- Customized education and support of provider treatments based on member’s specific needs.
- Education and support of services such as behavioral health as appropriate.
Who is included in this new program?
All fully insured members currently participating in AIM and Anthem programs are included.
The following groups are excluded: Self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP).
The AIM Back Pain Program microsite helps you learn more and access helpful information and tools such as program information and FAQs.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Blue Cross and Blue Shield Service Benefit Plan, also known as the Federal Employee Program, FEP, is now requiring new information on claims that are required by OBRA93 law to be priced at the Medicare allowance. Members that are over 64 years old and do not have Medicare Part B coverage fall under the OBRA93 law for Medicare pricing. In order for us to obtain the Medicare pricing, the CMS 1500 claim must have a rendering provider ID submitted on the claim . Claims submitted without the rendering provider ID will deny for the following message on the remit and require the provider to resubmit with this required field.
Remit message: 339 NEED PROVIDER NAME & NPI IN ORDER TO DETERMINE MEDICARE FEE SCHEDULE
This claim submission requirement applies to Federal Employee member claims only. A Federal member can be identified with an R followed by 8 digits. i.e., Rxxxxxxxx.
If you have any questions, please contact FEP Customer Service at 800-727-4060.
Effective with dates of service on and after October 1, 2022, and in accordance with the IngenioRx* Pharmacy and Therapeutics (P&T) process, Anthem Blue Cross and Blue Shield will update its drug lists that support Commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
Material Adverse Change (MAC)
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s Medical Specialty Drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health (AIM®*), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
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Clinical Criteria
|
Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0217
|
Amvuttra™ (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere® (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
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Clinical Criteria
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Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0217
|
Amvuttra (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
As a reminder, when billing medical drug codes to Anthem Blue Cross and Blue Shield, include these three components:
- National Drug Code (NDC)
- Quantity
- Unit of measure
To prevent possible denial of the of the billed code, please ensure all three components are included in the claim.
Medicare Advantage
On December 1, 2022, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for the following code. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code:
L6715 — Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement
Not all PA requirements are listed here. Detailed PA requirements are available to providers on the provider website at https://www.anthem.com/provider/news/archives/?cnslocale=en_US_co&category=medicareadvantage or by accessing Availity* at https://availity.com.
Providers may also call Provider Services for assistance with PA requirements by referencing the number on the back of the patient’s member ID card.
Medicare Advantage
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
|
HCPCS or CPT® codes
|
Medicare Part B drugs
|
|
J0172
|
Aduhelm (aducanumab-avwa)
|
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are [three] options for submitting attachments:
- Through the attachments dashboard inbox:
- From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
- Through the 275 attachment:
- Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
- Through the Availity.com application:
- From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
If you submit your claim through the Availity application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
ATTACHMENTS (available on web): 2690 image.jpg (jpg - 0.06mb) This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are [three] options for submitting attachments:
- Through the attachments dashboard inbox:
- From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
- Through the 275 attachment:
- Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
- Through the Availity.com application:
- From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
If you submit your claim through the Availity application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
Medicaid
Effective September 1, 2022, Anthem Blue Cross and Blue Shield Healthcare Solutions will transition to the InterQual® 2022 criteria to include updates from March and April 2022.
If you have questions, contact Provider Services at 844-396-2330.
Medicaid
Effective for dates of service on and after October 1, 2022, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon precertification initiation or renewal in addition to the current medical necessity review of all drugs noted in the chart.
The Clinical Criteria are publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS codes
|
|
ING-CC-0166
|
Preferred
|
Kanjinti
|
Q5117
|
|
ING-CC-0166
|
Non-preferred
|
Herceptin
|
J9355
|
|
ING-CC-0166
|
Non-preferred
|
Herzuma
|
Q5113
|
|
ING-CC-0166
|
Non-preferred
|
Ogivri
|
Q5114
|
|
ING-CC-0166
|
Non-preferred
|
Ontruzant
|
Q5112
|
|
ING-CC-0166
|
Non-preferred
|
Trazimera
|
Q5116
|
Medicare Advantage
Policy Update
Modifiers 25 and 57: Evaluation and Management with Global Procedures
(Policy G- 06003)
The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Anthem Blue Cross and Blue Shield. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.
For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://www.anthem.com/medicareprovider.
Medicaid
Please continue to check Medicaid Provider Communications & updates at anthem.com/nvmedicaiddoc for the latest Medicaid information, including:
|