To advance our operations towards a more digitally efficient model, when a care provider registers for electronic remittance advice (ERA/835), we will cease issuing paper remittances 30 days after the effective registration date. Care providers will receive their remittance electronically through ERA with the option to print copies via Availity Essentials as needed in the Remit Inquiry application located in Payer Spaces.

Some care providers, despite successful registration, continue to receive remittances in both electronic and paper formats. We are actively addressing this redundancy by discontinuing the issuance of printed remittances. As a result, care providers who have enrolled for ERA/835 but are still receiving paper remittances will begin noticing a decrease in these paper transactions starting in late August.

If you have yet to register for ERA and wish to switch to electronic remittance reception, we recommend that you configure your ERA settings through Availity Essentials or by working with your existing clearinghouse vendor. In the interest of facilitating electronic transactions, care providers interested in receiving electronic payments are encouraged to visit the EnrollSafe Enrollment Hub (payeehub.org).

This transition is part of our ongoing commitment to streamlining our procedures, enhancing customer experience, and promoting environmental sustainability.

Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (Anthem) 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. Refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

New medical policies effective December 1, 2024

Revised medical policies and clinical guidelines effective December 1, 2024

De-adopted clinical guidelines effective July 1, 2024

Archived medical policies effective June 28, 2024

The 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.

Nevada Medical Policies and Clinical UM Guidelines are available online:

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed at anthem.com > select Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as your state. Select View Medical Policies & UM Guidelines (tinyurl.com/26drkr5n). Either enter a keyword or code or select the link Full List page (tinyurl.com/tb3xkwuu) 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 (tinyurl.com/26drkr5n). Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada (tinyurl.com/yc2y4n9t).

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Quarter 1, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit Provider Medical Policy Search Results | Anthem.com.

Notes/updates:

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

• LAB.00039 - Combined Pathogen Identification and Drug Resistance Testing; Previously Titled: Pooled Antibiotic Sensitivity Testing:
• Revised title
• Revised Position Statement to address “combined pathogen identification and drug resistance” testing
• OR-PR.00008 - Osseointegrated Limb Prostheses:
• Outlines the Medically Necessary and Not Medically Necessary criteria for the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss.
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures:
• Revised Medically Necessary criteria for basivertebral nerve ablation (BVNA)
• SURG.00162 - Implantable Shock Absorber for Treatment of Knee Osteoarthritis:
• Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered Investigational & Not Medically Necessary.
• CG-DME-53 - Biomechanical Footwear Therapy:
• Biomechanical footwear therapy is considered Not Medically Necessary for all indications.
• CG-LAB-32 - Cancer Antigen 125 Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for the tumor marker cancer antigen 125 (CA-125) testing.
• CG-MED-94 - Vestibular Function Testing:
• Revised Medically Necessary and Not Medically Necessary statements to include vestibular-evoked myogenic potential tests
• CG-MED-96 - Prefabricated External Infant Ear Molding Systems:
• Outlines the Medically Necessary, Reconstructive and Cosmetic & Not Medically Necessary criteria for the use of prefabricated external infant ear molding systems to treat external ear malformations and deformations.

Medical Policies

On February 15, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect September 15, 2024.

Clinical UM Guidelines

On February 15, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on March 28, 2024. These guidelines take effect September 15, 2024.

• LabCorp is Anthem's preferred lab, providing broad services including complex diagnostic testing.
• Non-participating lab referrals, like Quest Diagnostics, may increase member costs and risk legal violations.

• Anthem members can find LabCorp locations and other participating labs online.

It is important that you refer Anthem members to participating labs. LabCorp is our preferred lab provider and offers a single-source solution to your testing needs. The relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories. Physicians may continue to refer to all par providers as they have in the past.

Not only does your Anthem agreement obligate you to refer to participating labs where available, but members will only receive their full benefits from participating care providers. Referring your patient and our member to a non-participating lab may expose them to greater financial responsibility.

Unfortunately, there are certain non-participating labs that are offering to waive or cap co‑payments, coinsurance, or deductibles to our members to increase their overall revenue. These practices undermine member benefits and may encourage over-utilization of services.

These billing practices are also questionable in their legality. Such a practice may present violations under state or federal anti-kickback laws.

For a listing of Anthem participating laboratories, please check our online directory. Go to anthem.com. Select Providers and then Providers Overview. Select Find Resources in Your State and select Nevada. From the Provider Home tab, select the enter button from the blue box on the left side of the page titled Find a Doctor (anthem.com/find-care).

Note: When searching for laboratory, pathology, or radiology services, under the field, I am looking for a: select Lab/Pathology/Radiology, and then under the field, Who specializes in, select Laboratories, Pathology, or Radiology as appropriate for your inquiry.

LabCorp is our preferred lab provider and can provide services that range from routine testing (such as basic blood counts and cholesterol tests) to highly complex diagnosing of genetic conditions, cancers, and other rare diseases. LabCorp has specialized laboratories, which cover the following areas of testing:

Note: This relationship with LabCorp does not affect network hospital-based lab service providers or contracted pathologists.

To find a LabCorp location near you, go to labcorp.com or call one of the phone numbers below.

For information about specialized assays or about requirements for special collection kits and specimen handling, call LabCorp at 303-792-2600 or toll-free at 888-LABCORP (888-522-2677).

We are committed to finding solutions that help our care provider partners offer quality services to our members.

Anthem will be updating prior authorization requirements for durable medical equipment (DME) rentals.

Check prior authorization requirements

Please refer to the Precertification Lookup Tool for detailed information on prior authorization requirements:

• Navigate to providers.anthem.com/nv.
• Select Resources from top menu.
• Select the Precertification Lookup Tool.
• Enter the Line of Business, the code you are inquiring about, and select the Search button to find prior authorization/precertification requirements.

Request prior authorization

You can request prior authorizations directly in Availity:

• Navigate to Availity.com.
• Select Patient Registration from the top menu, then select Authorizations & Referrals, and finally select Authorization Request.

DME services

Effective October 1, 2024, rentals for DME services listed below will require prior authorization:

Contact Us

For immediate assistance, contact Provider Services at 844-396-2330 or access Availity.com and chat with a live agent or send a secure message.

The following services will be added to precertification effective December 1, 2024.

Eligibility and benefits can be verified by accessing Availity Essentials at availity.com or by calling the number on the back of the member’s identification card. Service precertification is based on the member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for the verification of member eligibility and covered benefits.

Except in the case of an emergency, failure to obtain precertification before rendering the designated services listed below may result in denial of reimbursement.

Effective December 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these 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(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider. Choose the Select a State ribbon and then find on the Resources tab. Contracted providers can also access Availity.com. 

The Federal Employee Program^® (FEP) offers a quality reimbursement program for providers. Coding for CPT^® II category codes for A1c results, blood pressure readings, and the first prenatal visit are reimbursed at $10 per code.

The program has been a success in improving HEDIS^® scores and data collection. The FEP Quality Reimbursement Program for PPO providers was revised as noted below effective May 12, 2023.

Revisions to CPT II category II code requirements for $10 reimbursement:

• Only professional HCFA billing providers
• Only these six places of service codes are applicable:
  • 2 — telehealth not home
  • 10 — telehealth home
  • 11 — office
  • 12 — home
  • 17 — walk-in clinic
  • 20 — urgent care
• Only a specific diagnosis code that coordinates with the applicable CPT II code

Submitting the claim

Submit the CPT II code in field 24 of the HCFA 1500 with a charge of $10.

Use the applicable CPT II code, place of service code, and diagnosis code according to the information below.

Blood pressure — systolic and diastolic readings

Reimbursable DX codes: I10, I11.9, I12.9, I13.10, I15, I15.1, I15.8, I15.9, I16.0, I16.1, I16.9

Hemoglobin A1c

Reimbursable DX codes: E10.8, E10.9, E11.8, E11.9

First prenatal visit

The first prenatal visit date of service must be on the claim (field 24A HCFA 1500) with the appropriate code.

Reimbursable DX codes: Maternity-related diagnosis code

For additional information about the FEP Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.

Anthem is excited to announce the development of the Blue National Physician Performance Dataset. This initiative is a collaborative approach between Blue Cross Blue Shield Association, Blue Health Intelligence (BHI), and Motive Medical Intelligence (MMI) to develop a consistent national approach to evaluating physicians at the National Provider Identifier (NPI) level that incorporates measures of quality of care, appropriateness of care, and cost/efficiency of care.

Effective January 1, 2025, Anthem may incorporate the Blue National Physician Performance Dataset in various ways, including but not limited to:

• Providing special opportunities to participate in product offerings.
• When members contact Anthem with requests for referral options.
• Developing provider designations in provider directory (FindCare) tools.
• Enhancing existing tools in FindCare and Cost Finder, such as Personalized Match, that assist members with identifying or sorting providers.

For more information on how physicians are evaluated within each of the three categories (quality, appropriateness, and cost), you can view the Blue National Physician Performance Dataset Evaluation Method.

If you have any questions about the Methodology or your score, contact your local provider relationship management representative

The specialty pharmacy updates for 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 Carelon Medical Benefits Management, Inc.

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.

The inclusion of a 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 or after December 1, 2024, 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.

* Oncology use is managed by Carelon Medical Benefits Management.

Site of care updates

Update: In the May 2024 edition of Provider News, we announced the site of care review requirements for the following drugs would be effective August 1, 2024. Please be advised that the following drugs were not implemented to have SOC requirements added.

Access our Clinical Criteria to view the complete information for these site-of-care updates.

Step therapy updates

Effective for dates of service on or after December 1, 2024, 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.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about:

• Copayment/coinsurance requirements and their applicable drug classes.
• Drug lists and changes.
• Prior authorization criteria.
• Procedures for generic substitution.
• Therapeutic interchange.
• Step therapy or other management methods subject to prescribing decisions.
• Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner.

Want to reduce administrative burden and help your patients save on prescription costs?

With real-time prescription benefit (RTPB), care providers can access patient-specific drug benefit information within the e-prescribing process. This functionality allows care providers to proactively identify barriers to cost and improve medication adherence.

"Prescription pickup rates have increased 3.2% and saved patients on average $40 per prescription with using real-time prescription benefit.” — Surescripts.²

When using real-time prescription benefit during e-prescribing, care providers can see patient-specific benefit information including:

• Formulary status of selected medication.
• Patient cost share of medication at a retail and mail order pharmacy.
• Up to five formulary drug alternatives.
• Coverage alerts, including prior authorization and step therapy.

Benefits you and your patients will experience when using RTPB:

• Clearer, faster information
• Opportunity to lower cost barriers
• Decreased administrative burden
• Reduced time to therapy
• Enhanced patient experience

How real-time prescription benefit works:

1. Prescriber enters prescription information through e-prescribing.
2. The e-prescribing system triggers a data call to the pharmacy benefit manager (PBM).
3. The PBM receives the real-time prescription benefit request.
4. The PBM delivers cost, formulary, and utilization information for the selected pharmacy back to the prescriber’s electronic health record (EHR).
5. Prescriber and patient make a choice together.

Help your patients save money on their prescriptions with EHR access to patient-specific drug coverage and out of pocket costs. Find out if your EHR vendor provides real-time prescription benefits information. There’s no charge for the service; however, you will need the latest version of your EHR.

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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.

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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.