Provider News New HampshireMay 2023 Provider News Contents
NHBCBS-CRCM-023175-23 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
Moving Toward Equity in Asthma Care CME Training and Asthma Medication Ratio HEDIS measure update Moving Toward Equity in Asthma Care Anthem Blue Cross and Blue Shield is committed to achieving health equity in asthma outcomes with diverse populations. As part of this commitment, we offer an online training, Moving Toward Equity in Asthma Care. This course is accessible from any mobile device or computer and provides one continuing medical education credit at no cost to you. Visit www.mydiversepatients.com. Asthma Medication Ratio (AMR) HEDIS® measure The National Committee for Quality Assurance (NCQA) is also working to identify and reduce disparities in care. As part of this effort, race and ethnicity stratifications were added to the AMR HEDIS metric this year. The AMR metric measures the percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year. Did you know: - Hispanics and African Americans with asthma are less likely to take daily controllers and are more likely to visit the ER and be hospitalized for asthma-related conditions than non-Hispanic whites? 1
- Asian Americans are more likely to die from asthma than non-Hispanic whites?2
- Appropriate medication management for patients with asthma could reduce the need for rescue medication — as well as the costs associated with ER visits, inpatient admissions, and missed days of work or school?
Helpful tips: - Ensure at least half of the medications dispensed to treat asthma are controller medications throughout the measurement period.
- Talk to the patient about the importance of controller medication compliance, and not to use rescue medications on a regular basis, unless part of asthma action plan.
- Encourage patients to fill their prescriptions on a regular schedule rather than waiting till they are symptomatic.
- Create a written asthma action plan in language the patient understands, and schedule follow-up appointments with patients. Ask patients questions to assess asthma control, adherence to the action plan, and identify
- Utilize evidence-based asthma assessment tools to assess asthma control, adherence to the action plan, and identify triggers.
- Take the Moving Toward Equity in Asthma Care CME course at no cost for more helpful tips.
Additional resources Also available is the Asthma & Me training. Do your patients have asthma? Show them the pathophysiology of asthma in their preferred language. References: - Asthma and Allergy Foundation of America & National Pharmaceutical Council. (2005). Ethnic Disparities in the Burden and Treatment of Asthma. Retrieved from http://www.aafa.org/media/Ethnic-Disparities-Burden-Treatment-Asthma-Report.pdf
- U.S. Department of Health & Human Service, Office of Minority Health. (2016, May 9). Asthma and Asian Americans. Retrieved August 8, 2016, from https://www.minorityhealth.hhs.gov
- Asthma and Allergy Foundation of America. (2020). Asthma Disparities in America: A Roadmap to Reducing Burden on Racial and Ethnic Minorities. Retrieved from: https://aafa.org/wp-content/uploads/2022/08/asthma-disparities-in-america-burden-on-racial-ethnic-minorities.pdf
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). MULTI-BCBS-CM-019268-23-CPN18979 Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/provider, then under Provider Overview, select Find Care. Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include: - Add/change an address location
- Name change
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the form, we will send you an email acknowledging receipt of your request. The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. MULTI-BCBS-CM-022695-23-CPN22692 We’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. Engagement Hub 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 clinical quality.
- Offer care providers a convenient way to earn CME credits at a time that works best for you.
Register here for our free CME clinical quality webinars! Note: Sessions in this series are approved for one American Academy of Family Physicians credit each. MULTI-BCBS-CRCM-023027-23-CPN22728 MULTI-BCBS-CRCM-023141-23-CPN22841 Anthem Blue Cross and Blue Shield updates the provider manuals annually so that our care provider partners have the current information they need to work with us. The provider manual serves as a reference document and is reviewed internally each year to reflect changes to our processes and policies. The provider manual incorporates information for both professional and hospital/facility providers. The next update will be available on the website on May 1, 2023, and will become effective on July 1, 2023. To view the updated manual, please visit anthem.com. Select Providers, then Policies, Guidelines & Manuals. Select your state, scroll to Provider Manual, and select Download the Manual to view and/or download the provider manual as well as BlueCard and Medicare Advantage manuals. Archived copies of the professional and hospital/facility manual will remain available at the same location.
MULTI-BCBS-CM-020706-23-CPN20586 We are happy to once again be able to provide the 2023 Professional Provider Fee Schedule with the option to download through the Availity Essentials* platform. Starting in May 2023, professional providers who have been enrolled at that time will be able to review their upcoming fee schedule update that will go into effect as of July 1, 2023, and can be accessed through the reporting function in Availity Essentials. You can log into Availity.com and download a digital copy of your fee schedule. To be ready for the digital downloads, log in to Availity Essentials, access the Provider Online Reporting application, and register your authorized users. See details below on how to log in and access your reports. Provider Online Reporting reference guide How to get started This document will familiarize you with the Provider Online Reporting (POR) application found on the Availity Essentials platform. Using our web-based POR application, you will be able to access your updated fee schedule: - For Availity Essentials administrators – How to assign access
- For users – How to navigate to the reports
If your organization is not currently registered for Availity Essentials, go to Availity.com and select Register to complete the online application. Your administrator will need to take the following steps to assign access to Provider Online Reporting: - Assign the user role of Provider Online Reporting to your Availity access.
- Select Payer Spaces in the top menu bar and select the payer tile that corresponds to the market.
- First-time users accessing Payer Spaces will be asked to accept a Terms of Use Agreement. The agreement will appear for users once every 365 days.
- On the Applications tab, select Provider Online Reporting.
- Select your organization and select Submit.
- On the Welcome to Provider Online Reporting page, select Register/Maintain Organization.
- Select Register Tax ID(s) for the applicable program to register the tax IDs.
- A pop-up window will display all tax ID(s) that need to be registered for the program. Check the box for each tax ID to be registered and select Save.
- You now have successfully completed the tax ID registration. Notice after the registration has been completed, the status has changed from Register Tax ID(s) to Edit Tax ID(s).
Accessing reports: - Log in to Availity.com.
- Choose Payer Spaces in the top menu bar.
- Select the payer tile that corresponds to your market.
- Accept the User Agreement (once every 365 days).
- On the Applications tab, select Provider Online Reporting.
- Select organization and choose Submit.
- Select Report Search, choose the type of report, and then launch your program’s reporting application:
- The Home page in Provider Online Reporting will open. This page lists all programs the organization is eligible for.
- Use the navigation options on the left side of the page to easily move around within the tool.
The Programs page provides a description about the program your organization participates in and includes helpful documents related to your program, if applicable. Select a program using the drop-down menu. The Report Search page launches the corresponding reporting application for your program. Select the appropriate program from the drop-down menu. Helpful tip: Save Provider Online Reporting as a favorite. - Log in to Availity.com.
- Choose Payer Spaces in the top menu bar.
- Select the payer tile that corresponds to your market.
- On the Applications tab, select the heart icon next to Provider Online Reporting so it fills in and turns red.
- Now Provider Online Reporting will appear at the top under the My Favorites
- If you have questions regarding the Availity Essentials platform, contact Availity Client Services at 800-282-4548.
- If you have questions about POR, use the Contact Us section of the application.
- If you have other questions, contact your local Provider Relationship Management associate.
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. NHBCBS-CM-023584-23 Providers can submit corrected claims for Federal Employee Program, (FEP), members using Availity Essentials* or through Electronic Data Interchange (EDI). The FEP member ID number start with the letter R, followed by eight numerical digits. The corrected claims process begins when a claim has already been adjudicated. Multiple types of errors that occur can typically be corrected quickly with the options below. As a reminder, the corrected claim must be received within the timely filing. Availity Essentials corrected claim submission You can recreate a claim and submit it as a replacement or cancellation (void) of the original claim if Anthem has already accepted the original claim for processing. Follow these steps: - In the Availity Essentials menu, select Claims & Payments, and then select Professional Claim or Facility Claim, depending on which type of claim you want to correct.
- Enter the claim information, and set the billing frequency and payer control number as follows:
- Replacement of Prior Claim or Void/Cancel of Prior Claim.
- Billing Frequency (or Frequency Type) field, in the Claim Information section (for professional and facility claims) or Ancillary Claim/Treatment Information section (for dental claims). Use 7 for replacement claims and 8 for voided claims.
- Set the Payer Control Number (ICN / DCN) (or Payer Claim Control Number) field to the claim number assigned to the claim by Anthem. You can obtain this number from the 835 ERA or Remittance Inquiry on Payer Spaces.
- Submit the claim.
EDI corrected claim submission Corrected claims submitted electronically must also have the applicable frequency code and payer control number. Frequency code: - For corrected professional (837P) claims, use one of the following frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
- 7 — Replacement of prior claim\corrected claim
- 8 — Void/cancel prior claim
- For corrected institutional (837I) claims, use bill type frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
- 0XX7 — Replacement of prior claim
- 0XX8 — Void/cancel prior claim
Payer claim control number: - Use the original claim number assigned to the claim by Anthem.
Required EDI segments: - CLM05-3: Frequency Code (7,8)
- REF: Payer Claim Control Number (original claim number)
Please confirm with your practice management software vendor and billing service or clearinghouse for full details and information on submitting corrected claims. We encourage you and your staff to use the digital methods available to submit corrected claims to save costs in mailing, paper, and your valuable time. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CM-022819-23 Digital Request for Additional Information (Digital RFAI) is coming soon. When your organization registered to use the Medical Attachments application through Availity Essentials,* you also registered to receive digital notifications through that application. This makes it possible for Anthem Blue Cross and Blue Shield (Anthem) to notify you digitally when we need documents to process your claim. Beginning June 1, 2023, Anthem will notify you through your Attachments Dashboard when we need medical records, itemized bills, or other documents required to process our Commercial member claims. You will no longer receive a paper letter or remittance advice when we need documents to process most claims. Enabling more efficient processes Each morning, you will receive Digital RFAI notifications in your Attachments Dashboard Inbox for claims we are unable to process because we need supporting documentation. For certain claim types, we will pend the claim, rather than deny. You will have 30 days from the notification to digitally submit the needed attachments. If we don’t receive the needed attachments within 30 days, the claim will then deny, and you will receive a remittance advice. An additional notification will be posted to your Attachments Dashboard Inbox for up to 45 days to allow you to attach the documents to the notification. How to prepare to receive digital notifications: - Check your Medical Attachments application registration:
- If you are already registered to use the Medical Attachments application, make sure all your billing NPIs are correctly registered.
- Ask your Availity administrator to verify your registration.
- Use the self-service learning module to help your Availity administrator check your registration.
- Check your staff’s security:
- All team members needing access to attachment information should have these role assignments:
- Claims Status
- Medical Attachments
- Ask your Availity administrator to confirm all the role assignments are correctly applied to the right team members. They need to have access to the organization ID (customer ID) for which the billing NPIs are registered.
- Use the self-service learning module to help your Availity administrator check your team members role assignments.
Help, training, and support In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration: Date | Start Time | April 24, 2023 | 2 p.m. Eastern time | April 28, 2023 | 2 p.m. Eastern time | May 10, 2023 | 2 p.m. Eastern time |
Availity administrators can use this link to register for live training or to view the live training. For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient: Date | Start Time | May 11, 2023 | 2:30 p.m. Eastern time | May 12, 2023 | 11 a.m. Eastern time | May 15, 2023 | 11 a.m. Eastern time |
Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training or to view the live training. Through this efficient process, we are receiving needed support documentation 50% faster than through the outdated method of mailing letters and receiving attachments through non-digital methods.1 If you are using the PWK process to submit attachments, you may still receive Digital RFAI notifications in your dashboard, if: - You didn’t send us the correct document.
- We need additional documents.
- The PWK attachment wasn’t received within seven days.
Resources available Use the helpful resources for information that can help for a smooth transition to Digital RFAI notifications: For additional resources, call Availity Client Services at 800-282-4548.
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CM-023002-23-CPN22936 Effective May 1, 2023, we will enhance the Provider News website and email communications as part of our commitment to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year. Stay tuned for more updates. View the Quick Reference Guide for more information. NHBCBS-CRCM-016124-22-CPN15788 Effective August 1, 2023, Anthem Blue Cross and Blue Shield will transition the clinical criteria for medical necessity review of MRI Breast to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines: - Oncologic Imaging
- Chest Imaging
As part of this transition of clinical criteria, the following procedures will be subject to prior authorization at Carelon Medical Benefits Management: CPT® code | Description | 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; unilateral | 77049 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; bilateral |
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| HCPCS | Description | C8903 | Magnetic resonance imaging with contrast, breast; unilateral | C8905 | Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral | C8906 | Magnetic resonance imaging with contrast, breast; bilateral | C8908 | Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral |
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-021989-23-CPN21926 The following new and revised Medical Policies and Clinical Guidelines were endorsed at the February 16, 2023, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Medical Policies and Clinical Guidelines for Anthem Blue Cross and Blue Shield, are available at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select your state. Then, select View Medical Policies & Clinical UM Guidelines. To view Medical Policies and Clinical Utilization Management Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® [FEP]), visit www.fepblue.org > Policies & Guidelines. Medical Policy updates New Medical Policy effective August 1, 2023 The following policy is new: - MED.00145 Digital Therapy Devices for Treatment of Amblyopia
Revised Medical Policies effective August 1, 2023 The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational: - MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
- SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
Clinical Guideline updates Revised Clinical Guideline effective August 1, 2023 The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary: - CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Beginning with dates of service on or after August 1, 2023, Anthem Blue Cross and Blue Shield will implement a new facility reimbursement policy titled Bundled Supplies and Services – Facility. This policy identifies certain services and/or supplies ineligible for separate reimbursement when reported by a facility. These identified services and/or supplies are an integral component to the overall procedure. The Related Coding section of the policy lists and describes the Current Procedural Terminology (CPT®) and Healthcare Common Procedural Coding System (HCPCS Level II) codes that are considered always bundled and not eligible for reimbursement when they are reported as a stand-alone service, or with another service. No modifiers will override the denial for the always bundled services and/or supplies. For specific policy details, visit the reimbursement policy page at anthem.com.
MULTI-BCBS-CM-022955-23-CPN22784 Beginning with dates of service on or after August 1, 2023, Anthem Blue Cross and Blue Shield’s Robotic Assisted Surgery – Professional reimbursement policy will expand to include CPT® codes for computer-assisted surgical systems. This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed. The Related Coding section of the policy has been updated to include the following computer assisted surgical musculoskeletal navigation procedures: - 0054T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
- 0055T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
- 20985: Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)
The policy has been renamed to Technology Assisted Surgical Procedures – Professional and Facility, which defines both robotic assisted and computer assisted techniques. For specific policy details, visit the reimbursement policy page at Anthem.com. MULTI-BCBS-CM-022961-23-CPN22785 Beginning with dates of service on or after August 1, 2023, Anthem Blue Cross and Blue Shield’s Multiple and Bilateral Surgery Processing – Professional reimbursement policy will be updated to include two new CPT® codes for the Esophagogastroduodenoscopy (EGD) code family. This policy allows reimbursement for multiple and bilateral procedures. Reimbursement is based on Centers of Medicare & Medicaid (CMS) standard multiple and bilateral procedure rules for multiple arthroscopic and endoscopic surgical procedures. The Related Coding section has been updated to include the following new CPT codes released by CMS for the Esophagogastroduodenoscopy (EGD) code family: - 43290 — Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon:
- Added CPT code 43290 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent
- 43291 — Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s):
- Added CPT code 43291 to base code 43235 Esophagogastroduodenoscopy (EGD) with the reduction of 100% primary and 25% subsequent
For specific policy details, visit the reimbursement policy page at anthem.com. MULTI-BCBS-CM-022967-23-CPN22812 One of the greatest responsibilities Anthem Blue Cross and Blue Shield (Anthem) has to our members is to administer their benefits accurately. We conduct prepay itemized bill reviews for inpatient and outpatient services to ensure member cost shares are correctly applied. We have recently made the determination that our members would be best served if we were to require itemized bills for inpatient services billed in excess of $50,000 and outpatient services billed in excess of $20,000. On August 1, 2023, you will be required to make a change when submitting itemized bills for Anthem inpatient and outpatient member claims: - For inpatient services, submit an itemized bill for member claims in excess of $50,000.
- For outpatient services, submit an itemized bill for member claims in excess of $20,000.
- The itemized bill should be equal to the amount billed in order for us to process the claim.
At this time, this change only applies to fully insured members. We want to reduce the impact to your billing area as much as possible, so we have introduced a process that will: - Reduce the time needed to identify a fully insured member.
- Eliminate the need to submit itemized bills when not needed.
- Integrate with your existing workflows to enable electronic submission.
Anthem’s Digital Request for Additional Information (Digital RFAI) process enables you to submit itemized bills electronically through Availity.com.* The most efficient way to submit itemized bills is through the Digital RFAI process. This is how it works: - You submit your claim through either EDI or the Availity.com Claims & Payments application.
- If an itemized bill is needed, we send a notification to your Attachments Dashboard on Availity.com each morning by 8 a.m. Eastern.
- You retrieve the notification and upload the itemized bill directly to your claim as an attachment.
If an itemized bill is not required for the claim, you will not receive a notification, and the claim will continue through processing. Another benefit of the Digital RFAI process is the claim will pend (rather than deny), allowing up to 30 days for you to supply the requested itemized bill. Access the Digital RFAI webpage for learning resources, pre-recorded demonstrations, and more. - Start by viewing the Digital Request for Additional Information Training session.
- For help with Availity medical attachment setup, access this video for additional instructions.
- Not registered with Availity Essentials?* Here’s a link to get started with Availity.
For more information, view the Digital RFAI webpage online.
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CM-022822-23 The following Clinical Criteria documents were endorsed at the February 24, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information. New Clinical Criteria effective August 1, 2023 The following Clinical Criteria are new: - CC-0230 Adstiladrin (nadofaragene firadenovec-vncg)
- CC-0233 Rebyota (fecal microbiota, live – jslm)
Revised Clinical Criteria effective August 1, 2023 The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary: - CC-0062 Tumor Necrosis Factor Antagonists
- CC-0086 Spravato (esketamine) Nasal Spray
- CC-0096 Asparagine Specific Enzymes
- CC-0110 Perjeta (pertuzumab)
- CC-0115 Kadcyla (ado-trastuzumab)
- CC-0116 Bendamustine agents
- CC-0119 Yervoy (ipilimumab)
- CC-0120 Kyprolis (carfilzomib)
- CC-0128 Tecentriq (atezolizumab)
- CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
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 the Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* 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. Including the National Drug Code (NDC) code on your claim may 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 August 1, 2023, 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 site of prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | J9999 | CC-0062 | Idacio (adalimumab-aacf) | J3490, J3590 | CC-0231 | Lamzede (velmanase alfa-tycv) | C9399, J3490 | CC-0232* | Lunsumio (mosunetuzumab-axgb) | C9399, J3490, J3590, J9999 | CC-0233 | Rebyota (fecal microbiota, live – jslm) | C9399, J3490, J3590 | CC-0234 | Syfovre (pegcetacoplan) | C9399, J3490 | CC-0116* | Vivimusta (bendamustine) | J9999 |
* Oncology use is managed by Carelon Medical Benefits Management, Inc. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Site of care updates Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our site of care review process. Access our Clinical Criteria to view the complete information for these site of care updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0217 | Amvuttra (vutrisiran) | J0225 | CC-0194 | Cabenuva (cabotegravir extended-release; rilpivirine extended-release) | J0741 | CC-0003 | Cutaquig (immune globulin) | J1551 | CC-0210 | Enjaymo (sutimlimab-jome) | J1302 | CC-0018 | Nexviazyme (avalglucosidase alfa-ngpt) | J0219 | CC-0019 | Reclast (zoledronic acid) | J3489 | CC-0075 | Riabni (rituximab-arrx) | Q5123 | CC-0075 | Ruxience (rituximab-pvvr) | Q5119 | CC-0202 | Saphnelo (anifrolumab-fnia) | J0491 | CC-0212 | Tezspire (tezepelumab-ekko) | J2356 | CC-0075 | Truxima (rituximab-abbs) | Q5115 | CC-0207 | Vyvgart (efgartigimod alfa-fcab) | J9332 | CC-0220 | Xenpozyme (olipudase alfa) | J0218 |
Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be removed from our site of care review process. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0004 | Acthar (corticotropin) | J0800 | CC-0034 | Berinert (C1 Esterase Inhibitor, Human) | J0597 | CC-0034 | Firazyr (icatibant) | J1744 | CC-0154 | Givlaari (givosiran) | J0223 | CC-0034 | Kalbitor (ecallantide) | J1290 | CC-0013 | Mepsevii (vestronidase alfa) | J3397 | CC-0073 | Prolastin-C (alpha-1 proteinase inhibitor) | J0256 | CC-0156 | Reblozyl (luspatercept) | J0896 | CC-0034 | Ruconest (C1 Esterase Inhibitor, Recombinant) | J0596 |
Quantity limit updates Effective for dates of service on and after August 1, 2023, 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. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | J9999 | CC-0062 | Idacio (adalimumab-aacf) | J3490, J3590 | CC-0231 | Lamzede (velmanase alfa-tycv) | C9399, J3490 | CC-0233 | Rebyota (fecal microbiota, live – jslm) | C9399, J3490, J3590 | CC-0234 | Syfovre (pegcetacoplan) | C9399, J3490 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-022993-23-CPN22815 The fax number on the previous communication was incorrect and has been corrected here. The correct fax number is 833-678-0223. For services beginning on July 1, 2023, prior authorization requests for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services will be reviewed by Carelon Post Acute Solutions, LLC.* The goal of this program is to ensure members receive the right product for the right duration of time in the home. This change will be applicable to the following markets: Colorado, Connecticut, Georgia, Indiana, Kentucky, Missouri, New Hampshire, Nevada, Ohio, Virginia, and Wisconsin. How to submit or check a prior authorization request For DMEPOS services, Carelon Post Acute Solutions will begin receiving requests on Tuesday, June 20, 2023, for dates of service July 1, 2023, and after. Providers are encouraged to request authorization using the website. Go here to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions at 833-678-0223. Please note: Carelon Post Acute Solutions will not review authorization requests for products/services that do not fall under Medicare-covered products/services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras. To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit the website or email. If you have additional questions, please call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622. * Carelon Post Acute Solutions, LLC is an independent company providing services on behalf of the health plan. MULTI-BCBS-CR-024043-23-CPN24014 Who is affected For women ages 67 to 85 who sustained a recent fracture, it is important to obtain a bone density scan to assess for osteoporosis. How can we collaborate? We can help your patients complete this scan in the comfort of their home through Quest HealthConnect™.* In home resources We are working with Quest HealthConnect, a Quest Diagnostics service, to provide this service at no added cost to you. Quest HealthConnect will call your patient to arrange a visit. Patients may also call them directly at 888-306-0615 between 8:30 a.m. to 4 p.m. Eastern Time. The result(s) of the screening test(s) will be sent to both the patient and your office after the visit. * Quest Diagnostics is an independent company providing preventive care technology and health risk assessments services on behalf of the health plan. MULTI-BCBS-CR-017880-23-CPN17332 For professional claims submitted on a CMS-1500 form processed on or after June 1, 2023, Anthem Blue Cross and Blue Shield will enhance our editing systems to automate edits and simplify remittance messaging. These edit enhancements are supported by correct coding guidelines as documented in industry sources such as Correct Procedural Terminology (CPT®) guidelines and Centers for Medicare & Medicaid Services (CMS). Additionally, these edit enhancements will promote faster claim processing and reduce follow-up audits and/or record requests for claims that are not consistent with correct coding guidelines. As a result of these edit enhancements, there will be greater attention on identifying inappropriate billing of genetic testing services. Below are examples of claim edits focused on identifying inappropriate billing of genetic testing services that will be automated: - Multianalyte Assays with Algorithmic Analyses (MAAA) — CPT 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
- Panel testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists.
Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual.
If you have questions on this program, contact your Provider Relationship Account Manager. MULTI-BCBS-CR-019035-23-CPN18337 Please continue to check for the latest Medicare Advantage information, including:
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